“Wise Eyes” are more likely to have abnormalities of the eyelid anatomy including malposition (is the abnormal positioning of the eyelids), trichiasis (lash misdirection) and madarosis (lash loss). Aging of the eyelid is associated with a decrease in elastic fibers and in the overexpression of elastin-degrading enzymes. Chronic inflammation, subsequent fibrosis, and scarring may occur. These changes have been demonstrated in cases of ectropion and entropion.[1] These abnormalities are thought to be due to localized ischemia (when blood does not flow properly to your eye’s optic nerve), inflammation, or mechanical stress. The posterior lamella shortens causing the lid to turn inward. Unchecked, these patients are at risk of symblepharon, lid margin keratinization, severe meibomian gland loss, and vision loss.
Similar changes result in madarosis (absence or loss of the eyelashes and sometimes the eyebrows) and trichiasis (ingrowth or introversion of the eyelashes). While eyelash loss is symptomatically associated with thyroid disease, it may also be associated with chronic lid inflammation. Inflammation and scarring of eyelash follicles change lash appearance patterns. There is a frequent association between trichiasis and cicatricial entropion.[2]
Patients who present with cicatricial entropion, ectropion, lash misdirection, and the absence or loss of the eyelashes may require immediate intervention. Temporary treatments include ocular lubricants, contact lenses, and mechanical epilation (removal of eyelashes) to reduce foreign body sensation and corneal insult. Surgical treatments offer initial benefits but recurrence of symptoms are frequent due to chronic inflammation.
Options for chronic lid inflammation
Options for the control of chronic lid inflammation may include topical steroids, topical NSAIDS, oral Omega-3 fatty acids, oral doxycycline, topical azithromycin, and topical hypochlorous acid solutions. Topical steroids may increase intraocular pressure and should not be used long term in glaucoma patients.1 Topical NSAIDs typically present a price barrier to patients in FDA approved dosing formulations, and older formulations may cause discomfort upon installation. Omega-3 fatty acids may be contraindicated in patients taking blood thinners for cardiovascular disease. Oral doxycycline may cause gastrointestinal upset and may not be tolerated long-term by some patients. Topical azithromycin, while effective, comes in a 2.5 mL bottle that may not last 30 days before needing to be refilled. I often recommend a hypochlorous acid solution or gel for these patients because it is easy to apply, inexpensive, and effective at reducing inflammation at the lid margin. Many appreciate the “natural” alternative as much as the price of hypochlorous solutions, which aids patient compliance long-term.
[1]Damasceno RW, Avgitidou G, Belfort R Jr, Dantas PE, Holbach LM, Heindl LM. Eyelid aging: pathophysiology and clinical management. Arq Bras Oftalmol. 2015 Sep-Oct;78(5):328-31. doi: 10.5935/0004-2749.20150087.
[2] Ferreira IS1, Bernardes TF, Bonfioli AA. Trichiasis. Semin Ophthalmol. 2010 May;25(3):66-71. doi: 10.3109/08820538.2010.488580.
