The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Inward misdirection of eyelashes towards the cornea, secondary to a number of conditions
These include distichiasis, in which an extra row of lashes grows from the Meibomian gland orifices

Due to failure of epithelial germ cells to differentiate completely to Meibomian glands; autosomal dominant inheritance

Entropion of any cause (see Clinical Management Guideline on Entropion)
Metaplasia of Meibomian glands leading to abnormal growth of lashes is usually secondary to severe chemical burn, Stevens-Johnson syndrome, ocular cicatricial pemphigoid, or chronic blepharoconjunctivitis

Predisposing factors

Staphylococcal blepharitis
Trachoma (a form of chronic conjunctivitis caused by Chlamydia trachomatis, which leads to tarsal conjunctival scarring, entropion and trichiasis)
Cicatricial conditions (Stevens-Johnson syndrome, ocular cicatricial pemphigoid, chemical trauma, mechanical trauma including surgery)
Herpes zoster ophthalmicus


Ocular discomfort, irritation, foreign body sensation affecting one or both eyes
(NB: in the elderly and in people with diabetes, corneal sensitivity may be reduced)
Watery eye
Red eye


Lash or lashes in contact with ocular surface
Conjunctival injection
Corneal epithelial abrasion
Fluorescein staining of cornea and/or conjunctiva
Long-standing complications

  • pannus
  • corneal ulcer
  • infective keratitis

Differential diagnosis

Other causes of ocular irritation / red eye

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Epilation: remove lash(es) with forceps. Advise patient that lash(es) will re-grow within 4-6 weeks, therefore epilation may need to be repeated
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

If due to entropion, tape the eyelid for temporary relief of symptoms
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Consider therapeutic contact lens (silicone hydrogel soft, rigid mini-scleral or scleral) for temporary relief of symptoms
(GRADE*: Level of evidence=low, Strength of recommendation=weak)


Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

(NB Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations.

Lid hygiene for associated blepharitis

Management category

Mild cases requiring epilation only:
B2: alleviation/palliation: normally no referral
More severe cases requiring surgical intervention:
B1: initial management (including drugs) followed by routine referral to ophthalmologist

Possible management by ophthalmologist

Electrolysis: destruction of lash follicle by passing electric current into lash root. Suitable for single or small numbers of lashes. May require multiple treatments
Cryotherapy: nitrous oxide cryoprobe eliminates large numbers of lashes; may cause skin depigmentation
Radiofrequency ablation
Laser photocoagulation: repeated application of laser burns to the hair root and follicle. Various lasers have been used
Treatment of predisposing ocular conditions
Lid surgery if trichiasis secondary to entropion e.g. eyelid tightening in the form of everting sutures and lateral tarsal strip. For trachoma trichiasis, full thickness tarsotomy and rotation of lash bearing tissue has been shown to be effective

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see

Sources of evidence

Başar E, Ozdemir H, Ozkan S, Cicik E, Mirzataş C. Treatment of trichiasis with argon laser. Eur J Ophthalmol. 2000;10(4):273-5

Burton M, Habtamu E, Ho D, Gower EW. Interventions for trachoma trichiasis. Cochrane Database Syst Rev. 2015 ;11:CD004008

Ferreira IS, Bernardes TF, Bonfioli AA. Trichiasis. J Semin Ophthalmol. 2010;25(3):66-71.

Johnson RL, Collin JR. Treatment of trichiasis with a lid cryoprobe. Br J Ophthalmol. 1985;69(4):267-70

Plain language summary

In trichiasis, the eyelashes point inwards towards the eye rather than outwards as normal. Rarely, the condition may run in families, so that babies may be born with it. Much more commonly it results from either entropion (turning in of the lower lid resulting from age-related slackness of the tissues) or long-standing inflammation of the eyelids which can cause abnormal eyelashes to grow out of the oil glands on the edge of the eyelid. In global terms the commonest cause of trichiasis is trachoma, an infection spread by flies and between people, which affects at least 150 million people worldwide. Trachoma occurs throughout the world, but especially among people in developing countries and in poor rural communities.

People with trichiasis usually have uncomfortable red eyes and a feeling of something in the eye. The optometrist will see that one or more lashes are in contact with the eye surface. This may cause damage to the eye surface, which can then become infected. The optometrist may decide to pull out the offending lashes, using fine forceps. However, the lashes will usually grow again within four to six weeks, so this is only a temporary solution. Sometimes a bandage contact lens is fitted to relieve the patient’s symptoms. If the problem persists, the optometrist will refer the patient to the ophthalmologist, who may decide to remove the lashes by electrolysis, cryotherapy (freezing treatment) or laser treatment. If the cause is entropion, a minor surgical operation may be all that is required.

Version 12
Date of search 16.04.20
Date of revision 29.05.20
Date of publication 20.08.21
Date for review 15.04.22
© College of Optometrists

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