Ectopic Eyelashes: Causes and Treatment

Ectopic eyelashes, along with conditions like trichiasis and distichiasis, can cause significant discomfort and potential eye damage. Understanding the causes, diagnosis, and treatment options for these conditions is crucial for effective management and preserving vision.

Understanding Eyelash Abnormalities

Several terms describe abnormalities related to eyelashes and their growth:

Trichiasis: Defined as normal lashes growing inward. In trichiasis, the lash follicle is normal, but the direction of lash growth is abnormal. The lash is misdirected by abnormal direction of the shaft of the hair. In the presence of inflammation, there may be a misdirection of the follicle with the lash growing inwards towards the cornea, but the cause is not entropion. Some authors have divided trichiasis into primary where the lash is misdirected by abnormal direction of the shaft of the hair and secondary trichiasis where there is a misdirection of the follicle. Others have classified trichiasis as minor (less than five cilia) and major (more than five cilia).
Distichiasis: Defined as a separate row of lashes that are present behind the normal row of lashes. These lashes are fine with little pigmentation but will cause corneal irritation. Various forms of distichiasis are seen, from a complete row of lashes to an irregular row.
Ectopic Cilia: Lashes that are found away from their normal location, which is the eyelid margin. This condition is seen when the lashes grow through the tarsal plate and present in an area of the upper or lower eyelid, but the roots of the lashes are not at the eyelid margin.

Read also: Removing Magnetic Eyelashes: Step-by-Step
Pseudocilium: Sometimes, an eyelash will be seen in a meibomian gland orifice or the punctum. We have termed this "pseudocilium" because the lash does not have a root but is loose in the meibomian gland or the punctum.

Anatomy and Development of Eyelashes

There are approximately 100 cilia on each upper eyelid and 50 on the lower eyelids. The eyelash roots are located on the anterior surface of the tarsus. Meibomian glands are specialized sebaceous glands that line the eyelid margin and secrete lipids that form the superficial layer of the tear film. There are approximately 25 glands in the upper eyelid and 20 in the lower eyelid. Meibomian glands and eyelashes differentiate from a common pilosebaceous unit during the 2nd month of gestation. The dual potentiality of the pilosebaceous unit explains the etiology of both congenital and acquired forms of distichiasis.

Causes of Ectopic Eyelashes and Related Conditions

The causes of misdirected or abnormally located eyelashes are varied and can be broadly categorized as congenital or acquired.

Congenital Causes

Distichiasis: May be congenital, in which case the pilosebaceous units differentiate into lashes instead of meibomian glands.
Lymphedema-Distichiasis Syndrome (LDS): In the autosomal lymphedema-distichiasis syndrome, distichiasis is associated with limb lymphedema, and there may be cleft palate and cardiac abnormalities. Clinical diagnosis for LDS requires either lymphedema and distichiasis, distichiasis and a family history of lower-limb lymphedema, or lower-limb lymphedema and a family history of distichiasis. Identification of a heterozygous pathogenic variant in FOXC2 by a combination of gene-targeted testing and comprehensive genomic testing. The condition has high penetrance, but variable expressivity and severity is highly variable even within the same family.
Other congenital causes of distichiasis include mandibulofacial dystonia and Setleis syndrome (focal facial dermal dysplasia with upper eyelid lashes present in multiple rows or eyelashes may be completely absent).
True ectopic cilia are seen congenitally. A positive family history of ectopic cilia may be obtained.

Acquired Causes

Inflammation: Secondary distichiasis is seen in conditions that cause inflammation which in turn leads to metaplasia of the Meibomian glands forming lashes within the Meibomian glands. In acquired distichiasis, there is eyelid inflammation (Meibomian gland dysfunction, cicatricial pemphigoid, Stevens-Johnson syndrome).
Eyelid Margin Scarring: Scarring of the eyelid margin secondary to inflammation should be looked for.
Infections: Chlamydia trachomatis causes trachoma: the disease is endemic in sub-Saharan Africa. In trachoma, inflammation of the eyelid margin and conjunctiva will cause a combination of trichiasis as well as cicatricial entropion.
Other conditions associated with trichiasis:
- Chronic blepharitis
- Vernal keratoconjunctivitis
- Chemical burns (where both lids are affected) or trachoma, where the upper eyelid is more severely affected
- Thermal injury
- Eczema
- Herpes zoster
- Atopic diseases
- Ocular cicatricial pemphigoid disease
- Cicatrizing conjunctival disease
- Eyelid trauma
- Eyelid surgery
- Meibomitis
- Stevens-Johnson syndrome
- Leprosy
- Eyelid tumors
- Chalazia: Sometimes one will see trichiasis at a site of a prior chalazion which may or may not have been surgically drained: the collapsed meibomian gland can cause a local change in the architecture with lashes turning in.

Other Eyelash Conditions

Hypotrichosis: Defined as reduced hair density anywhere in the body may also affect eyelashes.
Madarosis: Is the loss of lashes (ciliary madarosis) or eyebrows (superciliary madarosis). Milphosis means eyelash loss. Madarosis and milphosis are often used interchangeably.
- Causes of Madarosis:
  - Blepharitis
  - Meibomian gland dysfunction
  - Ocular rosacea
  - Seborrheic blepharitis
  - Staphylococcal infection
  - Demodex infestation
  - Trachoma
  - Congenital syndromes like Oliver-McFarlane and Cornelia de Lange
  - Alopecia Universalis is a type of alopecia which also results in loss of lashes. In this condition, corticosteroids and topical immunotherapy have been used successfully to achieve hair growth.
  - T-cell lymphoma and associated follicular mucinosis
  - Allergic contact dermatitis may be caused by many cosmetics and ophthalmic medications with preservatives and other chemicals.
  - Superficial inflammation from any cause can lead to irritation and rubbing of the brows and lashes with pigmentation, skin laxity and lash loss.
  - Psoriasis
  - Atopic dermatitis, which may be associated with allergic rhinitis, keratoconjunctivitis, vernal conjunctivitis causes loss of lashes on the lateral third of the brows (termed Hertoghe’s sign).
  - Acne rosacea results in blepharitis, keratitis, and telangiectatic changes on the cheeks and nose
  - Alopecia areata may result in a patchy lash loss.
  - Discoid lupus erythematosus and systemic lupus erythematosus: chronic blepharoconjunctivitis and madarosis may occur.
  - Scleroderma en coup de sabre, which is localized scleroderma will show a segmental loss of eyebrows and lashes
  - Hypothyroidism may cause brittle hairs mostly affecting the brows, but also lashes
  - Hyperthyroidism may cause ciliary madarosis
  - Malignancy: basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, mycosis fungoides (cutaneous T-cell lymphoma), sebaceous cell carcinoma. Recalcitrant dermatitis and chronic blepharoconjunctivitis or recurrent chalazia should be indications for biopsy of the eyelid and eyelid margin.
  - Chemotherapy
  - Herpes zoster is a common cause of madarosis of the upper or lower eyelid.
  - Secondary syphilis can cause outer eyebrow loss and eyelash loss.
  - Leprosy as a cause is seen less frequently now.
  - HIV/AIDS may cause madarosis or trichomegaly.
  - Drugs: Systemic drug toxicity and local topical agents may cause madarosis.
  - Trauma: Eyelid lacerations, chemical, and thermal injuries and tattooing can all cause madarosis.
  - Trichotillomania is a condition in which patients pull hair (scalp being the most common, followed by eyelashes). As these are episodic, may be confused with alopecia areata. A biomicroscopic examination will show broken hairs of different lengths with no underlying skin condition.
Trichotillomania: Is the self-induced pulling of hair from anywhere in the body but is also applied to eyelash-pulling.
Hypertrichosis: (Hypertrichosis lanuginosa acquisita [HLA])
- Drugs
- Metabolic diseases
- Endocrine diseases
- Paraneoplastic processes: patients may develop increased lanugo develop lanugo hairs in the periocular, ear, forehead and nose areas.
- Anorexia nervosa
- Atopic dermatitis
- Allergic rhinitis (results in long smooth lashes)
- Dermatomyositis
- Hypothyroidism
- Malnutrition
- Pregnancy
- Hypothyroidism
- Porphyria
- Systemic lupus erythematosus
- Linear scleroderma
- Vernal keratoconjunctivitis
- Uveitis
- Voght Koyanagi Harada syndrome
- HIV/AIDS may cause trichomegaly as well as madarosis
- Many drugs have been associated with trichomegaly, causing thickening and even curling.
Cilia Incarnata: Is a term used to describe an eyelash that burrows under the skin to either the surface (cilium incarnatum externum) or posteriorly through the tarsal conjunctiva (cilium incarnatum internum). The eyelash root is normal, just the direction of growth of the shaft of the lash is abnormal.
Eyelash Ptosis: Is defined as a downward curve or bend to the upper eyelid lashes.

Diagnosis

A thorough eye examination is essential for diagnosing ectopic eyelashes and related conditions.

Biomicroscopy: Examination under the biomicroscope should assess the lid margin, the posterior lamella, and fornices (looking for symblepharon or scarring). An examination will reveal lashes pointing backward rubbing against the conjunctiva or the cornea. The lashes may be in their normal position may be growing from behind the normal eyelashes.
Slit Lamp Microscopy: The diagnosis of all three conditions is made under the slit lamp microscope.
Differential Diagnosis: Trichiasis is differentiated from involutional entropion, where the eyelid margin turns in and causes normal lashes to rub against the cornea.
Additional Tests: Your veterinarian will perform a Schirmer tear test to measure tear production and evaluate whether the affected eye is producing enough tears to keep it moist, and a fluorescein stain over the surface of the eye to make corneal ulcers visible. Determination of intraocular (within the eye) pressure is also an important test in evaluating the eye. This test will allow your veterinarian to evaluate the level of fluid pressure inside the eye.

Treatment

The primary goal of treatment is to alleviate irritation, protect the cornea, and prevent further complications. Treatment options vary depending on the specific condition, severity, and underlying cause. Surgical treatment should only be undertaken after active inflammation is brought under control.

Read also: Unlock Lash Potential

Conservative Management

Ocular Lubricants: Twice-daily use of a lubricating gel or ointment will improve the tear film and may reduce irritation in mild cases.
Short-term Relief: Short-term relief may be obtained by epilating the lashes or inserting a bandage contact lens.
Treating Underlying Conditions: With such a disparate list of causes of eyelash milphosis (madarosis), the underlying condition has to be diagnosed and treated.

Eyelash Removal Techniques

Epilation (Plucking): Your provider can pluck hairs out using tweezers (forceps), but this isn’t permanent. The hairs may grow back in the right direction, or they may grow back in the same position and continue to irritate the eye. Manual epilation is temporary because eyelashes normally grow back in 2-3 weeks.
Electrolysis: Electrolysis is a way to remove hair permanently. A fine electrode is inserted into each gland opening alongside the emerging hair. A current is applied to attempt to permanently destroy the hair follicle preventing regrowth of the distichia. Only those hairs present at the time of treatment can be identified and treated, so new hairs may emerge at a later date and cause irritation. The treatment uses an electric current to destroy the hair root at the end of the follicle.
Cryotherapy (Cryoablation): Cryoablation is a way to remove hair follicles and roots using extremely cold gas. A probe is applied to the inner surface of the eyelid in the region of the hair follicles and the eyelid is then frozen to destroy the hair follicles. This procedure may also need to be repeated. Cryoablation, also called cryosurgery, is effective but can cause complications like scarring or changes in skin color.
Eyelid Splitting with Cryotherapy: Cryoablation is sometimes paired with a technique called eyelid splitting. The provider cuts into the eyelid to expose the hair follicles and then uses cryotherapy to destroy them.
Laser Ablation: Your provider may suggest using lasers to remove the misdirected eyelashes of trichiasis. An argon laser was the first type of laser used to treat trichiasis. The treatment may also use infrared diode lasers, ruby lasers and Nd:YAG lasers (neodymium-doped yttrium aluminum garnet lasers).
Radiofrequency Epilation: Permanent destruction of the roots of the offending lashes is achieved using numerous techniques, including radiofrequency epilation.

Surgical Procedures

Permanent destruction of the roots of the offending lashes is achieved using numerous techniques, including trephination, eyelash bulb extirpation, resection of the lash follicle, cryotherapy, and surgical repositioning.

Releasing Follicle Roots: Plastic surgeons have tested a newer technique for treating trichiasis that involves surgery to remove and reposition the hair follicles. The incision is glued back together. One advantage of this treatment is that your eyelashes remain in place, so your eyelashes are fuller. Some people don’t like the way they look with fewer eyelashes. The follicle release procedure lets you keep the eyelashes you have.
Lid split and treatment of the abnormal follicles:
Lamellar eyelid division and cryotherapy to the posterior lamella: Severe cases require lamellar eyelid division and cryotherapy to the posterior lamella as discussed above. Splitting of the eyelid lamella with cryotherapy was first introduced by Anderson et al. with a series of thirteen eyelids followed for 8-48 months. Seven eyelids (54%) remaining symptom free and six eyelids required either minor cryosurgical touch-ups, or occasional epilation of trichiatic lashes.

Other Treatments

Topical Bimatoprost: The only effective treatment for hypotrichosis is the use of topical bimatoprost ophthalmic solution 0.03%. It is applied to the lash bases, resulting in lashes which are thicker, longer and darker. Bimatoprost is thought to prolong the anagen phase of the lash cycle. Results are seen in 16 weeks. A recent concern is that some patients may show atrophy of orbital fat after prolonged use of such topical bimatoprost solution.

Post-Treatment Care

Recovery: You may have swelling or some pain from treating misdirected eyelashes.
Observation: Observe your cat's eyes and consult your veterinarian if you notice any recurrence of symptoms.
Hygiene: Keep the eyes clean, either with fresh water, or with a veterinarian recommended eye wash.

Special Considerations

Distichiasis in Animals: Distichiasis is a common condition in dogs where eyelashes develop in an abnormal location, emerging from the eyelid margin rather than the eyelid skin. Ectopic cilia typically occur in young dogs.
Distichiasis, Trichiasis, and Ectopic Cilia in Cats: Trichiasis, distichiasis, and ectopic cilia are eyelash disorders that are rarely found in cats.
Eyelash Transplants: Eyelash transplants have not gained popular acceptance because of the risk of trichiasis and lack of lifelike hair on the lid margin. Successful take is not predictable (depending upon the underlying disease and condition of the eyelid).

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