Distichiasis: An update on etiology, treatment and outcomes

Abstract

Distichiasis, an extra row of eyelashes emerging from meibomian gland orifices, occurs due to the metaplastic transition of sebaceous glands into the pilosebaceous unit. It can present congenitally, such as in lymphedema distichiasis syndrome, or secondary to acquired conditions, such as cicatrizing conjunctivitis, trachoma. This review summarizes the etiology of distichiasis, its presentation, the evolution of various surgical techniques, and their outcomes in human and animal eyes. The published literature has focused on the different treatment modalities and their outcomes; the etiopathogenesis of this condition remains elusive. Truncating mutations (missense, frameshift, and nonsense) in the Forkhead family gene FOXC2 are involved in the distichiasis–lymphedema syndrome. The treatment options are no different for congenital versus acquired distichiasis, with no specific available algorithms. Acquired distichiasis in cicatrizing ocular surface diseases is difficult to manage, and existing treatment options offer success rates of 50%–60%. The outcomes of electroepilation or direct cryotherapy are not as good as surgical excision of distichiatic lashes after splitting the anterior and posterior lamella under direct visualization. The marginal tarsectomy with or without free tarsoconjunctival graft has shown good results in eyes with congenital and acquired distichiasis. The details of differences between normal and distichiatic lash, depth, or course of distichiatic eyelashes remain largely unknown. Studies exploring the distichiatic eyelash depth might improve the outcomes of blind procedures such as cryotherapy or radiofrequency-assisted epilation.

Meibography-Guided Electroepilation for Congenital Distichiasis: A Novel Surgical Technique

“…The existing nonsurgical modalities of treatment include electroepilation and cryotherapy and surgical options include direct eyelash excision, lid splitting with cryotherapy/electrocautery to the eyelash root, and tarsoconjunctival excision with or without graft. [1][2][3][4][5][6][7][8][9][10][11] According to published literature, surgical options offer better and longer resolution of symptoms than non-surgical treatment. 1 Distichiatic eyelash ablation using either radiofrequency current or cryotherapy is advisable after splitting the lid into anterior and posterior lamella rather than blind application.…”

“…[1][2][3][4][5][6][7][8][9][10][11] According to published literature, surgical options offer better and longer resolution of symptoms than non-surgical treatment. 1 Distichiatic eyelash ablation using either radiofrequency current or cryotherapy is advisable after splitting the lid into anterior and posterior lamella rather than blind application. 3,[5][6][7][8]10 Then, the distichiatic eyelash root is directly visualized, and ablative treatment is applied.…”

“…The reported anatomical resolution rates vary from 20% to 84% at different follow-up periods from 12 to 24 months. 1,3,[5][6][7][8]10 The limitation of lid-splitting is the occurrence of trichiasis secondary to inflammation induced by ablation in the eyelid margin area. 5 Also, these patients frequently require resurgery, and an incisional surgical approach further increases the risk of complications.…”

“…C ongenital distichiasis is characterized by an extra row of eyelashes arising from the meibomian gland orifices present since birth. 1 The symptomatology of watering, photophobia, and redness in congenital distichiasis is secondary to the constant rubbing of distichiatic eyelashes on the ocular surface. Diagnosis is based on the clinical examination of the eyelid margin on a slit lamp where one can see the metaplastic cilia arising from the meibomian gland orifices.…”

“…Diagnosis is based on the clinical examination of the eyelid margin on a slit lamp where one can see the metaplastic cilia arising from the meibomian gland orifices. 1 Traditionally, these extra eyelashes are ablated using laser, cryotherapy, or electroepilation or managed surgically. [2][3][4][5][6][7][8][9][10][11] The surgical options include transconjunctival excision of metaplastic lashes, eyelash excision under direct visualization, and tarsectomy along with a mucous membrane graft for the excised tissue replacement.…”