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SURGICAL MANAGEMENT IN CASE OF TRICHIASIS
ANAMIKA K KELSHIKAR*, SHRIRANG PUROHIT**
*Ophthalmologist; **Hon. Plastic Surgeon, KBHB Hospital, Parel, Mumbai 400 012.
A surgical procedure to correct upper lid trichiasis is reported here. The trichiasis was surgically managed by anterior lamellar repositioning with lid everting sutures with lid split to achieve eversion of the misdirected eyelashes and thus prevent corneal complications.
INTRODUCTION
Trichiasis is an acquired aberrant growth of the cilia that arise from the anterior lamella and are misdirected towards the ocular surface. Prolonged inflammation of eyelid margin, or chronic infection mostly trachoma usually contributes to this condition. Trichiasis causes chronic irritation of cornea and conjunctiva leading to complications like conjunctivitis, keratitis, recurrent erosions, secondary vascularization, scarring and corneal opacity.[1] Surgery is indicated to prevent such complications and in cases where cornea is already involved.
CASE REPORT
A 60-year old lady presented to us with complaints of watering, itching and severe discomfort in her left eye. On examination the left eye upper lid margin showed mebomitis and trichiatic eyelashes (approximately 7-8 in number). The everted lid showed papillary reaction and some fibrosis. Conjunctiva was minimally congested and cornea had mild haziness. Slit-lamp examination with fluorescein stain showed multiple superficial punctate epithelial erosions. The patient was pseudophakic with posterior chamber intra-ocular lens implant in her both eyes. The posterior segment in both eyes was normal. Examination of the right eye was within normal limit. The Schirmers test was within normal limit.
In view of meibomitis, patient was instructed about lid hygiene in form of hot fomentation and lid scrub, and treated with Optithrocin eye ointment over lid margin and lubricating agents. Capsule Doxycycline (100 mg) twice a day was also given for three weeks. Despite repeated epilation, patient was still uncomfortable and cornea showed punctate epithelial erosion due to recurrent growth. So we decided to manage this surgically by, anterior lamellar repositioning with lid everting sutures and lid-split.[2]
Surgical Technique
Incision was marked with methylene blue at approximately 7 mm from the margin and then infiltrated with lignocaine 2% with adrenaline. Incision was taken and deepened it through the orbicularis muscle to expose the anterior surface of the tarsal plate throughout its width. Then dissection was carried out downwards till the roots of lashes were seen. Thus anteriorly, skin and orbicularis muscle was separated from the tarsal plate behind. This facilitates repositioning of the anterior lamella. The anterior lamella was pulled up in relation to the posterior lamella, and the correction was assessed. As it was found to be inadequate, incision was made along the length of the grey-line and deepened. This allowed extra-eversion of the lashes.
Next, lid-everting sutures were taken with non-absorbable 5-0 ethilon. Sutures were passed from the skin and orbicularis muscle 1-2 mm above the lashes, then through the tarsal plate approximately at upper border of tarsus and then back through the orbicularis muscle and skin again at the same level (i.e. 1-2 mm above the lashes). [3] Such sutures were passed, one in centre and two on either sides. Sutures were tied in such a way that the anterior lamella (skin and orbicularis) was drawn superiorly in relation to the posterior lamella (tarsus) and thus everting the lashes. Over-correction was aimed on table. Skin closure was done with the interrupted sutures.
Post-operative antibiotics were given systemically and locally. Ethilon sutures were removed after 3 weeks.
meibomitis and trichiasis.
showing eyelashes turned away from the eye.
DISCUSSION
Treatment is required if patient is symptomatic or if corneal complication exists. Lubricating agents should be used to protect the eye from irritation until definite treatment is performed.
Certain other treatment modalities like epilation, electrolysis and cryotherapy, that can be opted are sometimes unsatisfactory. Epilation is only a temporary measure and recurrent growth is bound to occur.[3] Electrolysis is applicable only in cases with limited involvement and is complicated with recurrences and scarring.[4] Cryosurgery is effective method but is associated with complications like depigmentation of skin and loss of normal anterior cilia.[5]
Splitting of eyelid at greyline with excision of marginal portion of tarsus can lead to entropion.
The above described surgical technique is quite simple, yet the following things need to be considered. While taking an incision, skin should be stretched and then carefully cut should be made or else it will become ragged. While passing the sutures through the tarsus, full thickness bite should be avoided. Sometimes if tarsus is thickened, passing sutures through it becomes difficult. Thus it should be done gently or else underneath structures might get damaged. Ends of the sutures should be identified correctly and then tightened. Over correction is always desirable.
This technique achieves satisfactory correction of trichiasis and protects the cornea and seems to be a promising technique.
ACKNOWLEDGEMENT
I take great pleasure in presenting this case managed by us at KBHB Hospital.
I am most grateful to my dearest teacher Dr. Anjali D Nicholson - a great ophthalmologist, who is a source of constant inspiration to me.
I am thankful to Dr. Anjaneya Agashe who also helped me. I am obliged to this patient who faithfully and regularly followed up with me and gave an opportunity to me to learn something new.
Above all, I dedicate this to my parents and especially to my lovely sisters - Santosh and Rupali. The virtue of this kind was not possible without the valuable support and encouragement of my sisters.
REFERENCES
1.Frederick T, Fraunfelder F, Hampton Roy, et al. Current ocular Therapy, 4th edition, WB Saunders Company. 1995; 601.
2.Tyers AG, Collin JRO. Colour Atlas of ophthalmic Plastic Surgery. 1st edition Churchill Livingstone @ Longman Group Limited. 1995; 80.
3.Frederick T, Fraunfelder F, Hampton Roy, et al. Current ocular Therapy, 4th edition, WB Saunders Company, 1995; 601.
4.Majekodunmi S. Cryosurgery in treatment of trichiasis. Br J Ophthalmol 1982; 66 : 337-9.
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