https://doi.org/10.1167/tvst.8.4.30 Article Potential Effect of Epilation on the Outcome of Surgery for Trachomatous Trichiasis Sandra Liliana Talero1, Beatriz Munoz˜ 2, and Sheila K. West2 1 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA 2 Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, MD, USA Correspondence: Sheila K. West, Purpose: To evaluate the association of epilation before surgery on the surgical Johns Hopkins University, Wilmer outcome in trachomatous trichiasis (TT) patients. Eye Institute, 600 North Wolfe St, Baltimore, MD 21287, USA. e-mail: Methods: As a secondary data analysis, 1452 patients enrolled in the STAR trial were [email protected] categorized according to preoperative epilation status. The main outcome was recurrent trichiasis after surgery. We used multivariable analysis, time-to-event Received: 2 August 2018 analysis, and Cox proportional hazards model. Accepted: 29 April 2019 Published: 21 August 2019 Results: Those who epilated prior to surgery tended to be older and female, with worse entropion at baseline. The proportion with postoperative trichiasis was 7.7%, Keywords: trichiasis; trachoma; 8.8% in those who epilated versus 5.3% in those who did not (P 0.03). Adjusting for epilation; postoperative trichiasis ¼ age and sex, the risk of postoperative TT with epilation was 1.71 (P value ¼ 0.02). Citation: Talero SL, Munoz˜ B, West Although entropion may be in the biological pathway from epilation to postoperative SK. Potential effect of epilation on TT, we adjusted for entropion, and the risk of postoperative TT with epilation was 1.41 the outcome of surgery for tracho- (P ¼ 0.14). matous trichiasis. Trans Vis Sci Tech. 2019;8(4):30, https://doi.org/ Conclusions: The study suggests that preoperative epilation may increase the risk of 10.1167/tvst.8.4.30 postoperative trichiasis. Further research is needed to confirm the finding. Copyright 2019 The Authors Translational Relevance: Patients with TT often self-treat, epilating their inturned eyelashes. The World Health Organization recommends surgery to treat TT, but when patients refuse the procedure or mild trichiasis is present, epilation is often recommended. There is some evidence that repetitive or improper epilation can be harmful to the lid and hair follicles. If there is damage to the lid margin, any subsequent surgery could have deleterious outcomes. 5 5 Introduction health care professional. Rajak et al. reported 76.8% of TT patients in Ethiopia were epilating, with frequencies between once a week to once a month. Trachoma, the leading infectious cause of blind- ness worldwide,1 is the result of repeated infection WHO recommends surgery for all TT patients, 2 even if only one eyelash touches the eye. Surgery is with ocular strains of Chlamydia trachomatis. The 2,9,10 infections produce inflammation of the conjunctiva,2 effective in reducing pain and photophobia. 1,3 However, recurrence of trichiasis after surgery can and with repeated episodes, scarring develops that 11 leads to entropion and trichiasis.4,5 The eyelashes turn be as high as 50% after 2 years of follow-up. For this toward the eye and rub the cornea, leading to reason, WHO has recommended epilation for those 12 opacification and visual loss.1,6 who refuse surgery, and some countries’ programs The World Health Organization (WHO) defines offer epilation to those who have just a few lashes that 4,5 trachomatous trichiasis (TT) as at least one eyelash do not touch the cornea. touching the globe or evidence of recent epilation of This recommendation prompted a review of the inturned eyelashes.7 Persons with trichiasis report safety of epilation for persons with trichiasis. considerable pain,8 so they will epilate the trichiatic Epilation—depilation or plucking—involves the re- lashes, and have to do so repeatedly. The procedure is moval of the hair shaft and the bulb.13 The phase of commonly performed by the patient,6 a helper, or a growth of the eyelashes can influence the need and 1 TVST j 2019 j Vol. 8 j No. 4 j Article 30 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Downloaded from tvst.arvojournals.org on 09/26/2021 Talero, Munoz,˜ and West frequency of epilation; if the eyelash is plucked during the inactive phase of growth, activity and Methods regrowth are induced.14,15 A study in mice on the effect of plucking hairs during different phases of the We conducted secondary analyses using data from follicular cycle showed that plucking induced mitotic a randomized clinical trial of antibiotic use following activity, even with incomplete epilation,14 and trichiasis surgery, the Surgery for Trichiasis, Antibi- plucking during the anagen period reduced the otics to Prevent Trichiasis (STAR) Trial, which development period in the growing hair13,14 and enrolled patients in Wolayta Soddo zone of southern 16 Ethiopia in 2002. The design and outcomes of this can cause follicles to be damaged. Researchers 3,8,9,21–23 observed an increment in the thickness of the study have been reported previously. In epidermis16 where the club hair or inactive hair, short, we found that epilation prior to surgery did was plucked.14 With repetitive plucking, the epider- not differ between the two randomization arms and that use of a single dose of azithromycin post surgery mis became less responsive, possibly due to a 3 decrease in the number of stimulus-responsive significantly reduced trichiasis recurrence. For this cells.16 In human follicles, plucking alters the study, we used all the participants enrolled at baseline mesenchymal sheath of the hair, and the microtrau- (n ¼ 1452). ma produces edema, hyperemia, inflammation, and To be eligible, participants had to have upper lid hemorrhages.17 Also, repetitive epilation may per- trichiasis in at least one eye, have had no previous manently harm the matrix,13,16 the portion of the trichiasis surgery, and be age 18 years or older. At hair that grows actively18 and contains the follicular baseline, trained TT surgeons did the screening for stem cells.19 This damage to the matrix is in part trichiasis using a torchlight with patient’s eyes in explained by the removal of the stimulus-responsive primary gaze. We evaluated the presence of eyelashes cells.16 in contact with the eye, number of eyelashes touching In addition to epilation itself, the actual practice the globe and the cornea, location of trichiatic involves the use of a variety of tools and invasive eyelashes, age, gender, and the severity of entropion. methods, such as using hand- or machine-made Evidence of epilation was based on patient self-report forceps, burning the eyelash with hot coals, cutting and on the visualization of eyelash bases, short lash or pulling the eyelash with fingers,5 or using sticky stubs, or broken lashes. Entropion was categorized as tree resin to pluck the lash, as observed in the mild, moderate, or severe as follows: mild: all lash Amazon region. Epilation to treat minor trichiasis bases visible in the region with trichiasis; moderate: was associated with worse outcomes in a trial of one or more lash bases inturned, but some still visible; epilation versus surgery.4 severe: bases not visible. In general, common adverse effects described as Follow-up evaluations for postoperative trichiasis associated with epilation and the epilation methods were conducted at 2 weeks and 2, 6, and 12 months are as follows: discomfort, pain, irritation, scarring after the trichiasis surgery. The definition of postop- and burns of the skin, folliculitis and pseudofollicu- erative trichiasis was at least one eyelash touching the litis (especially in androgenized areas),20 and post- globe or new evidence of epilation. Study eyes were inflammatory hyperpigmentation of the lid.13,18 Poor removed from further follow-up if postoperative technique or poor quality of forceps can cause trichiasis was found. incomplete epilation and broken lashes5 that could The Johns Hopkins Medical Institutions Institu- produce more damage.6 tional Review Board (JHMI-IRB) and the Ethiopian While epilation is generally perceived as a relative- Science and Technology National Ethical Clearance ly harmless practice, the above findings suggest that Committee approved the study. Written informed there may be damage to the lid margin with repeated consent was obtained from all participants. epilation that could worsen the inflammation and the Data Analysis entropion already caused by trachomatous scarring. Moreover, preoperative epilation could negatively Data were analyzed using statistical software affect the outcome of surgery for trichiasis, although (Stata 15; StataCorp LLC, College Station, TX). there are no data on this. Patients were categorized into two groups, depending The purpose of the study was to evaluate the effect on whether there was evidence of epilation at baseline of epilation before surgery on the surgical outcome in or not. The data on epilation status were combined patients with TT. across both treatment arms and the results adjusted 2 TVST j 2019 j Vol. 8 j No. 4 j Article 30 Downloaded from tvst.arvojournals.org on 09/26/2021 Talero, Munoz,˜ and West by azithromycin use. Demographic and baseline the group of participants with a positive history of characteristics were analyzed by presence or absence epilation, as shown in Table 2. of epilation at baseline and were tested for differences The Figure shows the differences in time to using Pearson v2. Those characteristics found to be recurrence between the epilation and nonepilation different by epilation group were entered into the groups after 12 months of follow-up. The unadjusted multivariable models, with the exception of the risk of recurrence of TT after surgery was 65% greater variable ‘‘duration of trichiasis,’’ as only one case of in the group epilating before surgery compared with postoperative TT was found in the group with the group not epilating (P ¼ 0.031).