Eyelash disorders

Summary

Conditions such as infection, inflammation, involutional changes, trauma or malignancy can result in eyelash dysfunction. Therefore, understanding of lid margin anatomy and the various eyelash disorders is essential for a robust clinical examination of the external eye.

Anatomy of the lid margin

From anterior to posterior:

• Eyelashes

• The grey line

• The meibomian gland orifices

• The mucocutaneous junction

• Conjunctiva

Misdirected lashes

Trichiasis

• Misdirection of the eyelashes toward the globe, from individual follicles. Often due to inflammation such as chronic blepharitis, but can also be secondary to trauma such as incision and curettage of a chalazion

Marginal entropion

• There is not significant inversion of the eyelid, but the mucocutaneous junction advances anteriorally to the meibomian gland orifices, which results in the misdirection of the lashes

• The posterior edge of the eyelid adjacent to the globe also loses its squared edges and becomes rounded

• Typically involves numerous eyelashes

• This condition may be perceived as a pathology of the lashes instead of its correct designation as eyelid malposition.

Distichiasis

• Distichiasis is a congenital or acquired condition where eyelashes arise from the meibomian glands on the posterior lamella of the eyelid margin

• Congenital: the germ cells destined to differentiate into a meibomian gland instead develop into a pilosebaceous unit. We see a second row of aberrant lashes emerging at, or slightly behind the meibomian gland orifices

• Acquired: caused by metaplasia of the meibomian glands, into hair follicles. Important cause includes chemical injury, SJS, ocular cicatricial pemphigoid (all causes of intense conjunctival inflammation)

Management

• Epilation with tweezers/forceps (recurrence is inevitable)

• Electrolysis (requires local, can lead to scarring)

• Laser ablation (lashes that are localised, as opposed to diffuse respond well to electrical ablation)

• Tarsal facture for marginal ectropion

• Cryotherapy (high rate of adverse effects!)

Clinical features of trachoma. A: Active trachoma with both follicles and intense inflammation. C: Entropion trichiasis and corneal opacity. E: Misdirected lashes. Image Courtesy of

Eyelash ptosis

Downward angle of the eyelashes of the upper eyelid. Strongly associated with a condition known as floppy eyelid syndrome (a form of eyelid malposition).

💡 Eyelashes lack arrector pili muscles (the small muscles attached to most mammalian hair follicles which cause the hair to stand on end upon contraction). Eyelash position therefore depends upon support from surrounding structures. Therefore, anatomic changes to the upper eyelid are thought to be the cause of eyelash ptosis. In the case of floppy eyelid syndrome, Schlötzer-Schrehardt et al. has indicated that patients with this condition have less elastic fibre or elastin within the eyelid skin and tarsal plate compared to control subjects.

Trichomegaly

Eyelash trichomegaly is increased length (12 mm or more), curling, pigmentation or thickness of eyelashes.

Causes

Drug induced: topical prostaglandin analogues, phenytoin and ciclosporin

Other conditions: AIDS, porphyria, hypothyroidism

Congenital: Oliver–McFarlane syndrome, Cornelia de Lange syndrome

Madarosis

Madarosis is a clinical sign that refers to eyelash or eyebrow loss from any cause. This can be due to local causes (burns, radiotherapy, lid tumours), skin disorders, systemic disease (acquired syphilis, leprematous leprosy) or psychiatric (trichotillomania)

32 year-old presented with 3 month history of treatment for presumed chalazion. In B, we can see focal loss of eye lashes following treatment. Image courtesy of Sung et al.

Poliosis

Localised whitening of hair (eyelashes and eyebrow). Important causes to learn for the Duke Elder Exam include:

• Vitiligo

• Vogt Kayanagi-Harada syndrome

• Sympathetic ophthalmia

• Tuberous sclerosis

• Marfan syndrome

• Waardenburg syndrome.

Poliosis of the lashes eyebrows and scalp hair in Vogt Kayanagi Harada Disease. Image courtesy of Lavezzo et al.

References

1. Salmon, John F., and Jack J. Kanski. Kanski’s Clinical Ophthalmology: A Systematic Approach. Ninth Edition, Elsevier, 2020.

2. Erdoğan, Mustafa, and Şeyda Karadeniz Uğurlu. ‘Marginal Entropion: A Frequently Overlooked Eyelid Malposition’. Turkish Journal of Ophthalmology, vol. 45, no. 5, Oct. 2015, pp. 203–07. PubMed Central, https://doi.org/10.4274/tjo.20591.

3. Scheie, H. G. & Albert, D. M. Distichiasis and trichiasis: origin and management. *Am. J. Ophthalmol.*61, 718–720 (1966)

4. Schlötzer-Schrehardt U, Stojkovic M, Hofmann-Rummelt C, Cursiefen C, Kruse FE, Holbach LM. The pathogenesis of floppy eyelid syndrome: involvement of matrix metalloproteinases in elastic fiber degradation Ophthalmology, 112 (4) (2005), pp. 694-704

5. Kaur, Sandeep, and Bharat Bhushan Mahajan. ‘Eyelash Trichomegaly’. Indian Journal of Dermatology, vol. 60, no. 4, 2015, pp. 378–80. PubMed Central, https://doi.org/10.4103/0019-5154.160484.

6. Sachdeva S, Prasher P. Madarosis: A dermatological marker. Indian J Dermatol Venereol Leprol. 2008;74(1):74–6

7. Rajak, Saul N., et al. ‘Trachomatous Trichiasis and Its Management in Endemic Countries’. Survey of Ophthalmology, vol. 57–341, no. 2, Mar. 2012, pp. 105–35. PubMed Central, https://doi.org/10.1016/j.survophthal.2011.08.002

8. Sung, Dongjin, et al. ‘Early Onset Sebaceous Carcinoma’. Diagnostic Pathology, vol. 6, no. 1, Sept. 2011, p. 81. BioMed Central, https://doi.org/10.1186/1746-1596-6-81

9. Lavezzo, Marcelo Mendes, et al. ‘Vogt-Koyanagi-Harada Disease: Review of a Rare Autoimmune Disease Targeting Antigens of Melanocytes’. Orphanet Journal of Rare Diseases, vol. 11, Mar. 2016, p. 29. PubMed Central, https://doi.org/10.1186/s13023-016-0412-4