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Morphological Observations on Patients with Presumed Trichiasis

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Morphological Observations on Patients with Presumed Trichiasis Br J Ophthalmol: first published as 10.1136/bjo.72.1.17 on 1 January 1988. Downloaded from British Journal of Ophthalmology, 1988, 72, 17-22 Morphological observations on patients with presumed trichiasis K BARBER AND T DABBS From the Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield SJO 2JF SUMMARY The clinical findings in 116 patients with a provisional diagnosis of trichiasis are presented. In 69% a small degree of entropion producing lash-globe contact was detected. The term lid border entropion is proposed for this condition, which is recognised clinically by conjunctivalisation of the meibomian gland orifices and anterior placement of the mucocutaneous junction. These features were clearly demonstrated by electron microscopy of a biopsy specimen from one patient. An analysis of other causes of trichiasis is discussed and an attempt is made to clarify the terminology currently in use. A number of early descriptions of trichiasis exist, Face and eyelid photographs were taken to show mainly owing to its association with trachoma.' The anatomical details and to provide an accurate record. Ebers Papyrus which dates back to the 16th century BC describes it, as did Hippocrates in the 5th century Results BC. Despite this historical background, trichiasis has no universally accepted specific definition and can be The age of the patients varied from 20 to 89 years, used for a number of eyelid or eyelash abnormalities. with an average of 64 years. The onset of trichiasis for Many terms are used to describe it, including: each patient was noted and a histogram compiled. supernumerary lashes, metaplastic lashes, aberrant The onset of trichiasis was maximal between the ages lashes, pseudocilia, and distichiasis. It is probably of 60 and 70 years (Fig. 1). The average duration for http://bjo.bmj.com/ best regarded as an 'umbrella term' for conditions trichiasis in this group of patients is shown in Fig. 2: characterised by lash-globe contact. 58% had suffered from trichiasis for five years or A need exists to describe the morphology of more and 15% for 30 years or more. The patients trichiasis and to remove some of the confusion on its were attending an ophthalmic casualty, usually for terminology. We present here a study of the clinical epilation on a regular basis by nursing staff; 40% characteristics and morphology of a group of patients with presumed trichiasis. 30 on October 1, 2021 by guest. Protected copyright. Patients and methods One hundred and sixteen patients regularly attending an ophthalmic unit with a provisional diagnosis of 20 trichiasis were entered into the study. They were all a) undergoing intermittent epilation by nursing staff or -_X 1 specific treatment by medical staff. Most of the patients attended on a casual basis without appointment and, to estimate the demand at the unit for treatment, details of their age, duration of symptoms, and attendance rates were compiled. Each patient was examined and photographed. 10 20 30 40 50 60 70 80 90 Correspondence to K Barber, FRCS Ed, Worcester Eye f ospital, Age Barbourne Road, Worcester. Fig. 1 Age distribution ofpatients at onset oftrichiasis. 17 Br J Ophthalmol: first published as 10.1136/bjo.72.1.17 on 1 January 1988. Downloaded from 18 K Barber and T Dabbs 40, 35 - 30 - - LA 25 a) 20 0- 15 - 10 - 5-1 U U I -: 7 .1I--9 1 5 10 20 30 40 50 60 70 80 Years Fig. 3 Upper eyelid with conjunctivalisation ofmeibomian Fig. 2 Duration in years oftrichiasis. gland orifices. were attending between one and four times per patients (6%/) who regularly attended for epilation by month. The average rate of attendance was once nursing staff complained of irritation and believed every 7*5 weeks, and this resulted in approximately that this was due to trichiasis. On successive slit-lamp 10 patient visits per week. examinations these patients had no evidence of lash- Table 1 shows the distribution of morphological globe contact despite their symptoms. changes seen in this group of 116 patients. Seven The remaining 109 patients could be divided into 'NMI III http://bjo.bmj.com/ on October 1, 2021 by guest. Protected copyright. ,.e& Fig. 4 Leftlower lid trichiasis with conjunctivalscarring and lid border entropion (compare with normal righteye)-. Br J Ophthalmol: first published as 10.1136/bjo.72.1.17 on 1 January 1988. Downloaded from Morphological observations onpatients withpresumed trichiasis 19 Impippopp-.. ig. DA Fig. 5A: Scanning electronmicrograph ofa block ofeyelidfrom apatient with lid and border entropion. The mucocutaneous http://bjo.bmj.com/ junction isseen between the meibomian gland orifices and the lash line. B: Mucocutaneous junction showing division between squamous epithelium andconjunctivalepithelium. C: Microvilli on conjunctivalepithelium. those patients with eyelash abnormalities causing Misdirected lashes are therefore commonly seen in lash-globe contact and those with eyelid abnormali- trichiasis but are usually associated with other eyelid ties doing so. Only 14 patients had purely eyelash abnormalities rather than existing on their own. abnormalities. The great majority of patients (95) Distichiasis (defined as a congenital row of lashes on October 1, 2021 by guest. Protected copyright. had eyelid abnormalities causing lash-globe contact. arising from the meibomian gland orifices) was seen Seven patients had misdirection of lashes that were in only one patient. Metaplastic lashes (defined as an causing lash-globe contact, with an otherwise normal acquired row of lashes arising from the meibomian eyelid margin. Misdirected lashes were seen together gland orifices) were seen in three patients. Another with lid border entropion in 29 patients and in three patients had an extension of the normal eyelash association with lid margin notch in 16 patients. line medially and laterally involving the canthal regions. Recognising this as a cause of trichiasis is probably not justified. Table 1 Anatomical abnormalities seen in l16 patients In 95 patients (82%) a lid abnormality was present. Seventeen patients had lid margin notches secondary No abnormality 7 to temporary tarsorrhaphy or removal ofa lid tumour. Eyelash abnormalities: Misdirected 7 In these patients a normal lash line was present Metaplastic 3 Distichiasis 1 except in the notched area, where distortion of the Malposition 3 follicles resulted in misdirected lashes. Eyelid abnormalities: Lid border entropion 78 The most common lid abnormality consisted of a Lid border entropion and small degree of entropion, which we refer to as lid lid notch 2 border entropion. This condition was identified by Lid margin notch 15 conjunctivalisation of the meibomian gland orifices Br J Ophthalmol: first published as 10.1136/bjo.72.1.17 on 1 January 1988. Downloaded from 20 K Barber and TDabbs Fio. 51 and anterior placement of the mucocutaneous border villi surrounds the meibomian gland orifices, and the of the lid (Fig. 3). mucocutaneous junction is well demarcated with This is distinguishable from established involu- squamous epithelium in juxtaposition with conjunc- http://bjo.bmj.com/ tional lower lid entropion in that it is neither intermit- tival epithelium. There is no apparent transition tent nor invoked by forced closure of the eyelids. Fig. zone. 4 shows lid border entropion (left eye) with lash globe Eighty patients (69%) had lid border entropion contact. In this case conjunctival scarring has caused which caused lash-globe contact (Table 2). This was the lid border entropion. seen in association with conjunctival scarring in 41 Scanning electron microscopy was used to demon- patients. These patients were thought, therefore, to strate the position of the mucocutaneous junction in have a cicatricial lid border entropion. Thirty-nine on October 1, 2021 by guest. Protected copyright. lid border entropion and to establish the nature ofthe patients had lid border entropion without any epithelium at the lid margin in this condition. A evidence of conjunctival scarring. This has been corrective pentagon excision was performed on one termed involutional lid border entropion. patient with lid border entropion. Figs. 5A, B, C show the lid margin of this patient. The mucocutane- Discussion ous junction is well anterior to the meibomian gland orifices; normal conjunctival epithelium with micro- A certain amount of confusion exists regarding the terminology pertaining to trichiasis. Trichiasis is Table 2 Types of lid border entropion in 80 patients with derived from the Greek for hair, and is generally used trichiasis to denote irritation caused by lash-globe contact. Many associated terms are used to describe the Cicatricial upper lid border entropion 17 various forms of trichiasis, some of which are helpful Cicatricial lower lid border entropion 17 and others confusing. Cicatricial upper and lower lid entropion 7 Distichiasis has been well described."9 It is a Involutional lower lid border entropion 17 Involutional upper lid border entropion 22 congenital condition whereby a second row of lashes exists along the posterior border of the lid margin Br J Ophthalmol: first published as 10.1136/bjo.72.1.17 on 1 January 1988. Downloaded from Morphological observations onpatients withpresumed trichiasis 21 ww -P .1 #r. W//,. ift.'r-1-4VIN.1. 4i", ."', W.l.r,?, .:.6" .. .' . , " ". - . -, I--, .1 0 Iwo http://bjo.bmj.com/ Fig. iC in the position of the meibomian gland orifices. removal which involved the lash line without adequate Histology of such eyelids has shown lack of reconstruction of the lid margin. meibomian glands.267 The meibomian glands are The majority of patients (69%) in this study have a on October 1, 2021 by guest. Protected copyright. pilosebaceous units in which hair development is small degree of entropion of the lid border. Duke- absent."" Failure of differentiation of the pilosebace- Elder' mentioned this in passing but did not define ous unit results in lashes arising from the meibomian it, and Duane expressed difficulty in diagnosing gland region and is regarded as a form of atavism by entropion in patients with trichiasis." Collin'2 and some.8 Jones et al.
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