Part II Eyelids

CHAPTER 7

Eyelash disorders

Disorders of the eyelashes (cilia), and of associated struc-

tures at the base of the eyelashes such as the eyelash folli-
cles, glands of Zeis and skin of the lid margin, have
implications with respect to contact lens wear. Practitioners
need to be aware of the possible existence of such condi-
tions in contact lens wearers because they may explain
ocular discomfort during lens wear, and in many instances
will contraindicate lens wear until the condition is resolved.
Eyelashes typically project from the anterior rounded
border of the lid margin in two or three rows. They lie just
anterior to the ‘grey line’ – an anatomical feature that indi-
cates the position of the mucocutaneous junction. The supe-
rior eyelashes are longer and more numerous than those of
the lower lid. Because upper lashes normally curl up and
lower lashes normally curl down, lashes do not become
tangled on eyelid closure. Eyelashes are typically darker
than other hairs of the body except in conditions such as
alopecia areata.1
Figure 7.1 External hordeolum. (Courtesy of Brian Tompkins.)

External hordeolum (stye)

reasons, patients may prefer to cease lens wear during the
An external hordeolum – commonly known as a ‘stye’ – acute phase of the formation of a stye.
presents as a discrete inflamed swelling of the anterior lid
margin (Figure 7.1). It is extremely tender to touch, and
may occur singly or as multiple small abscesses. A stye is Blepharitis
an inflammation of the tissue lining the lash follicle and/or
an associated gland of Zeis or Moll. It is typically an acute Blepharitis is typically classified as being either anterior
staphylococcal infection, and as such commonly presents or posterior. The condition is sometimes called ‘marginal
in patients with staphylococcal blepharitis. blepharitis’ because it is observed along the lid margins.
Styes have a typical time course of about 7 days. Some- Anterior blepharitis is directly related to infections of
times a stye will discharge spontaneously in an the base of the eyelashes and manifests in two forms –
anterior direction. If a patient is in particular discomfort, staphylococcal blepharitis and seborrhoeic blepharitis.
resolution can be facilitated by removing the eyelash The severity of blepharitis can be quantified with refer-
from the infected follicle and applying hot compresses to ence to the grading scale for this condition that is pre-
the affected area.2 sented in Appendix A.
Contact lens wear may add to the discomfort of a stye Recent literature has used the terms posterior blepharitis
due to the mechanical effect of the lens. In soft lens wearers, and meibomian gland dysfunction (MGD) as if they were
mechanical pressure against the lens between the stye and synonymous, but these terms are not interchangeable.3 Pos-
the globe may effectively grip the lens and result in exces- terior blepharitis describes inflammatory conditions of the
sive lens movement during blinking. With a rigid lens fitted posterior lid margin, of which MGD is only one possible
interpalpebrally, the lens may buffer against the lid margin cause. In its earliest stages, MGD may not be associated
with each blink, causing considerable discomfort. For these with clinical signs characteristic of posterior blepharitis. At
© 2012 Elsevier Ltd
Chapter 7 Part II: Eyelids

this stage, affected individuals may be symptomatic, but In long-standing cases, there may be a loss of some eye-
alternatively, they may be asymptomatic and the condition lashes (madarosis), some eyelashes may turn white (polio-
regarded as subclinical. As MGD progresses, symptoms sis), and the anterior lid margin may become scarred,
develop and lid margin signs, such as changes in meibum notched, irregular or hypertrophic (tylosis).
expressibility and quality and lid margin redness, may Hypersensitivity to staphylococcal exotoxins may lead to
become more visible. At this point, an MGD related poste- secondary complication such as low-grade papillary and
rior blepharitis is said to be present3 (see Chapter 6). bulbar conjunctivitis, toxic punctate epitheliopathy involv-
ing the inferior third of the cornea, and marginal corneal
Staphylococcal anterior blepharitis infiltrates.
Patients suffering from staphylococcal anterior blephari-
This condition is caused by a chronic staphylococcal infec- tis may complain of burning, itching, foreign body sensa-
tion of the eyelash follicles, and leads to secondary dermal tions and mild photophobia. Associated tear film instability
and epidermal ulceration and tissue destruction. It is often may also lead to symptoms of dryness. Symptoms are often
observed in patients with atopic eczema and occurs more worse in the morning.
frequently in females and in younger patients. The following management strategies may be employed:
Slit lamp examination of patients suffering from this con-
dition reveals the presence of hyperaemia, telangiectasis • Antibiotic ointment – after removing crusts, antibiotic
and scaling of the anterior lid margins. The scales are brittle ointment is applied to the lid margins with a clean
(Figure 7.2) and when removed will leave a small bleeding finger.
ulcer. The lashes may appear stuck together and in severe • Promote lid hygiene – crusts and toxic products can
cases a yellow crust can form as a kind of sleeve that covers be removed by scrubbing the lids twice daily with a
the base of the eyelash; these sleeves are called ‘cuffs’ or commercially available lid scrub. Alternatively,
‘collarettes’ (Figure 7.3). regular washing with a warm, moist face cloth and
occasional rubbing with diluted baby shampoo should
alleviate the condition.
• Steroids – weak topical steroids may be tried in more
severe and protracted cases, especially if the strategies
described above fail.
• Artificial tears – will provide symptomatic relief if the
blepharitis is compromising the integrity of the tear
film.
The treatment can be tailed off as appropriate as the con­
dition improves. However, staphylococcal anterior ble­
pharitis is difficult to treat and the pattern of recovery is
characterized by periods of remission and exacerbation.2

Seborrhoeic anterior blepharitis

This condition is due to a disorder of the glands of Zeis and
Moll, which connect with eyelash follicles. It is frequently
associated with seborrhoeic dermatitis of the scalp, eye-
Figure 7.2 Staphylococcal anterior blepharitis with the lid margin covered brows, nasolabial folds, retroauricular areas and sternum.
in brittle scales. (Courtesy of Deborah Jones, British Contact Lens Association The symptoms are similar but less severe than for staphy-
Slide Collection.) lococcal anterior blepharitis.
The anterior lid margin displays a shiny, waxy appear-
ance with mild erythema and telangiectasis (Figure 7.4).
Soft, yellow greasy scales are observed along the lid margin
(Figure 7.5); unlike staphylococcal anterior blepharitis,
these scales do not leave a bleeding ulcer when removed.
The eyelashes may also become greasy and stuck together.
As with the staphylococcal form, secondary complica-
tions of seborrhoeic anterior blepharitis include mild papil-
lary conjunctivitis and punctate epitheliopathy. The main
form of treatment is lid hygiene and artificial tears.2

Implications for contact lens wear

Contact lens wear is generally contraindicated during an
acute phase of anterior blepharitis, especially if the cornea
is compromised. If contact lenses are worn during mild
cases of staphylococcal anterior blepharitis, attention to
lens cleaning is critical to prevent continued recontamina-
tion of the eye. Faherty4 suggests that contact lens wearers
Figure 7.3 Collarette in a patient with staphylococcal anterior blepharitis. should be advised to be careful of cross-contamination
(Courtesy of Brian Tompkins.) between eyes, lenses, lens solutions, and/or lens cases,
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 Eyelash disorders

must therefore be aware of this possibility, and must be

able to distinguish between the three species of parasite
that most commonly infest human eyelashes and associated
structures.6 This is especially important in contact lens prac-
tice, as failure to identify parasitic eyelash infestation will
almost certainly lead to patient dropout.

Mites
Mite infestation is very common in humans, with a greater
prevalence in older persons. In the USA, the prevalence of
mites has been reported to be 29% in 0 to 25-year-olds, 53%
in 26 to 50-year-olds and 67% in 51 to 90-year-olds.7 Mite
infestation in the eyelashes is ubiquitous and generally sub-
clinical, but if present in excessive numbers, adverse signs
and symptoms may develop. The mode of transmission of
mites between humans is not clear, but may arise from
intimate contact. Mites are also more abundant in diabetic
Figure 7.4 Seborrhoeic anterior blepharitis in which the eyelashes have and AIDS patients, and in patients on long-term corticoste-
become greasy and stuck together. (Courtesy of Deborah Jones, British roid therapy, suggesting that compromised immunity may
Contact Lens Association Slide Collection.)
also influence mite infestation.6
Two species of mite (Demodex) are found in the human
pilosebaceous gland complex; these are from the family
Demodicidae, order Acarina (mites and ticks), class Arach-
nida (spiders, scorpions, ticks and mites) and phylum
Arthropoda. Infestation with Demodex species is termed
‘demodicosis’.6

Demodex folliculorum
This is a cigar-shaped mite with four evenly spaced stubby
legs on the upper third of its body (Figure 7.6). It prefers to
live in the space between the eyelash and the follicle wall,
and in a single follicle will typically exist in small colonies
of three to five mites. This species of mite is always located
above the level of the gland of Zeis, primarily because of
its size.8

Figure 7.5 Yellow greasy scales along the lid margin in a patient with
staphylococcal anterior blepharitis. (Courtesy of Brian Tompkins.)

and to use cosmetics properly and with care. Daily dis-

posable contact lenses will eliminate such problems of
cross-contamination.
Keys5 conducted a 4-month study on 20 contact lens
wearers and six non-lens wearing patients suffering from
blepharitis, in order to test the efficacy of various treatment
regimens. These regimens were:
• eyelid cleaning with hypoallergenic soap;
• lid scrubbing with dilute baby shampoo; and
• use of a commercial lid scrub.
It was concluded that all three regimens resulted in
Figure 7.6 Electron micrograph of a follicle mite, Demodex folliculorum,
improvement, and that about 85% of patients preferred to
lying on an epilated lash. (Courtesy of Patrick Caroline.)
use the commercial lid scrub.

D. folliculorum is much smaller in diameter than the base

Parasite infestation of eyelashes of the eyelash; it buries itself head first into the follicle and
feeds off the cytoplasm of follicular epithelium by clawing
Infestation of the eyelashes by mites or lice can lead to signs away at, and puncturing, the epithelial cell walls with sharp
and symptoms that closely resemble blepharitis. Clinicians mouth-parts. The shredded, hyperkeratinized cell material,
69
Chapter 7 Part II: Eyelids

combined with lipids and sebum, form clear collarettes

(Figure 7.7; in cases of staphylococcal anterior blepharitis,
the collarettes have more of a creamy yellow appearance).
Extensive mite activity can lead to an aggregation of cuffing
material so that the mites are trapped within the hair fol-
licle. This can lead to follicle distension, granulomas, telan-
giectasis, hyperplasia, erythema, madarosis, hyperaemia,
burning and itching, which of course must be dealt with
clinically.6

0.1 mm

Demodex folliculorum Demodex brevis

Figure 7.8 The two species of mite (Demodex) are found in the human
pilosebaceous gland complex.

passing between eyelash follicles. Patient symptoms typi-

cally parallel the life cycle of the organisms. Nests of D.
folliculorum are laid around the base of lashes; they hatch
Figure 7.7 Collarette surrounding an eyelash of a contact lens wearer after about 2 to 3 days and the adult lives from 5 to 14
infested with mites. (Courtesy of Lourdes Llobet, Bausch & Lomb Slide days.10
Collection.)
Although they may be detected at high magnification
(×40) on a slit lamp biomicroscope, mites are difficult to
observe because they are very small (much narrower than
the width of an eyelash); they withdraw back into the fol-
Demodex brevis licle in bright light (being nocturnal in nature); and they are
This mite is found in human skin rich in sebaceous glands translucent. Diagnosis is confirmed by examination of epi-
and sebum production. It prefers to infest the gland of Zeis, lated lashes under a light microscope; one or more mites
and can get to this gland because of its very small size observed on every two lashes is considered to be indicative
(0.18 mm long, versus D. folliculorum which is 0.38 mm of demodicosis.11 Kojima et al.12 have recently demon-
long).7 (Figure 7.8). D. brevis has an almost identical struc- strated that Demodex infestation can be diagnosed using
ture to D. folliculorum, the former being shorter but stubbier. laser scanning confocal microscopy. Their results suggested
D. brevis is often found alone in a single sebaceous gland. that this technology not only effectively disclosed the mites
In a similar manner to the actions of D. folliculorum, D. brevis embedded in the eyelash bulbs, but also provided addi-
can block the gland of Zeis, and indeed can block meibo- tional useful information on associated MGD and conjunc-
mian glands, leading to meibomian gland dysfunction and tival disease, the features of which were acinar dilatation,
interference with lipid production, which in turn can result periglandular inflammation and conjunctival inflammatory
in dry eye symptoms. infiltrates.12
Because D. brevis prefers to live in an oily, sebaceous Additional signs of demodicosis include erythema of
environment, it tends to thrive in the presence of oily the lid margins, lid hyperplasia and madarosis (all of which
cosmetics and facial preparations. This in turn can cause give the impression of blepharitis), conjunctival injection,
D. brevis to proliferate, and can lead to the following cuffing around lashes, follicular distension, and meibomian
sequelae of events: meibomian glands, glands of Zeis, and gland blockage. Eyelashes are more easily removed during
other facial sebaceous glands become blocked; the skin active infestation due to damage to the eyelash follicles.
becomes dry; the patient applies more oily facial creams; D. Typical symptoms of demodicosis are pruritus, burning,
brevis again proliferates; and the cycle continues.9 crusting, itching, swelling of the lid margins and loss
of lashes. The itching often parallels the 10 day reproduc­
tive cycle.6
General characteristics Figure 7.9 is a schematic diagram illustrating the pre-
Demodex species are typically nocturnal, but even during ferred habitat of mites and lice that commonly infest the
the day a busy migration of organisms can be observed human pilosebaceous system.
70
 Eyelash disorders

Lice The crab louse, P. pubis, is most commonly found in

pubic hair, but also in other coarsely spaced hair such as on
Three species of lice infest the human body: the chest and thighs (Figure 7.11). Infestation with this
species is termed phthiriasis. The crab louse is about 1.0 to
• Head louse (Pediculus humanus capitis).
1.5 mm long, which is an ideal size for inhabitation among
• Body louse (Pediculus humanus corpus).
pubic hairs because these are spaced 2 mm apart and this
• Pubic louse (Phthirus pubis) or ‘crab’.
corresponds to the anatomical grasping span of its legs.
These species are from the family Pediculidae, order Ano- P. pubis can successfully infest eyelashes, which are also
plura (the sucking lice), class Insecta and, like mites, they approximately 2 mm apart; indeed, of the three species of
are classified as belonging to the phylum Arthropoda.6 louse discussed above, it is the crab louse that is almost
P. capitis typically infests the scalp hair (especially the exclusively found among human eyelashes.13 P. pubis has
occipital region). During dense scalp infestation, P. capitis two pairs of strong grasping claws on the central and hind
can be found in the eyelashes, but this is extremely rare. P. legs, allowing it to hold on to eyelashes with considerable
corpus inhabits seams and creases in clothing and feeds on tenacity.
the skin of patients. Infestation with these two species is Phthiriasis is considered a venereal disease because it is
termed pediculosis. The Pediculus species are typically 2.5 passed on by sexual contact. In adults, genital-to-eye trans-
to 3.5 mm long (Figure 7.10), and are a vector in humans mission is the most probable cause of eyelash infestation,
for serious diseases such as typhus, relapsing fever and although infestation from contaminated bedding, towels,
trench fever.13 and bed clothes is another possible mode of transfer. The

Eyelash Nits Collarette

Phthirus pubis Crusting Mite

(blood-sucking pubic louse) (Demodex folliculorum)

Epidermis Dermis Gland of Zeis

Eyelash follicle Mite

(Demodex brevis) Figure 7.9 Preferred habitat of mites and
lice that commonly infest the human
pilosebaceous gland complex.

Approximates separation Approximates separation

of pubic hair of head hair
First pair of All legs
legs are about
thinner than the same
second length
and third pair

Shorter Longer
abdomen abdomen

1.0 mm Pubic louse Body/head louse

(crab louse) Phthirus pubis Pediculus humanus corpus
Pediculus humanus capitus
Figure 7.10 Species of lice that infest the
human body.
71
Chapter 7 Part II: Eyelids

Signs of phthiriasis include pruritus of the lid margins,

blepharitis, marked conjunctival infection and madarosis.
Additional signs include preauricular lymphadenopathy
and secondary infection along the lid margins at the site of
lice bites. The most predominant symptom is intense
itching, which is so severe that patients will also report
insomnia, irritability and mental depression.13
The most obvious sign of phthiriasis is the presence of
oval, greyish-white nit shells attached to the base of lashes,
which are easily identifiable using high magnification (×40)
slit lamp biomicroscopy (Figure 7.13). Adult lice can be
difficult to detect because they are almost completely trans-
parent. Reddish-brown deposits at the base of lashes also
indicate the presence of lice; these deposits are a combina-
tion of blood from the host and faeces from the parasite.
Blue spots may also be observed on the lid margins; these
are due to enzymatic reactions from the digestive juices of
the lice.13
Figure 7.11 Electron micrograph of a crab louse, Phthirus pubis. (Courtesy
of Patrick Caroline, Bausch & Lomb Slide Collection.)

eyelashes of children may be infested by eye-to-eye contact,

and eyelashes of infants may be infested from contact with
chest hair of parents or siblings who themselves are har-
bouring the lice.6
The three species discussed above are known as ‘sucking
lice’ because of their mode of feeding, which is to anchor
mouth hooklets to the host skin and to extend a long hollow
tube (stylus) into the dermis. Anticoagulants are secreted
to facilitate unimpeded sucking of blood and serum.6
All of these lice have internal fertilization and lay eggs
within 2 days of fertilization. The eggs, or ‘nits’, are encap-
sulated in a cigar-shaped shell (Figure 7.12). Nit shells are
cemented to eyelashes about 1 to 2 mm from the base of the
lash, and the nits hatch in 7 to 10 days. It takes lice about
1 month to reach adult stage, and the adult lives for a
further month. Lice can survive for only 2 days if separated Figure 7.13 Slit lamp photomicrograph of a nearly-transparent louse at the
from the host.6 lid margin (arrow) surrounded by a mass of nits encapsulated in shells, and
some empty shells that have already hatched open. (Courtesy of Patrick
Caroline.)

Treatment of mite infestation

The main aim of treatment is to reduce the level of mite
infestation to sub-clinical levels. In treating this condition,
it should be assumed that there will be a concurrent bacte-
rial infection. The initial course of action is to attempt to
remove as many mites and mite eggs as possible. This can
be achieved by applying a topical anaesthetic and swabbing
the eyelid margins and eyelashes with a cotton-tipped
applicator saturated in a contact lens cleaning solution,
taking care to avoid contact with the cornea.6
Gao et al.14 reported the results of a retrospective review
of clinical results in 11 patients with ocular Demodex who
received a weekly lid scrub with 50% tea tree oil combined
with daily lid hygiene with tea tree shampoo. This treat-
ment regimen resulted in the Demodex count dropping to 0
for two consecutive visits in less than 4 weeks in eight of
11 patients. Ten of the 11 patients showed different degrees
Figure 7.12 Electron micrograph of lice eggs, or ‘nits’, encapsulated in a of symptomatic relief and notable reduction of inflamma-
characteristic cigar-shaped shell. (Courtesy of Patrick Caroline.) tory signs. Significant visual improvement in six of 22 eyes
72
 Eyelash disorders

was associated with a stable lipid tear film caused by sig- possibility of concurrent infestation of pubic hair. More
nificant reduction of lipid spread time. However, there was potent pediculicidal ointment can be applied to regions of
notable irritation in three patients. the body away from the eyes, offering the possibility of
Edmonson et al.6 report that patients should be advised rapid and effective treatment.13
to engage in vigorous lid scrubbing twice daily (morning The home environment should also be sanitized to eradi-
and evening) using commercially available preparations, cate lice, with heat application being the most effective
diluted baby shampoo, non-allergenic soap or hot flannels. course of action. Lice will be killed if bed clothing, towels,
Following the evening lid scrub, a viscous ointment should sheets and clothes are washed in boiling water for 30
be applied to the upper and lower lid margins. This proce- minutes. Combs, brushes and hair accessories should be
dure will: soaked in lice-killing products or in boiling water for 10
• trap mites in their follicles; minutes. Isolation of blankets and other large items from the
• smother and kill the trapped mites; and host for 2 weeks will ensure the death of all lice and nits.13
• prevent mites from migrating and cross-contaminating
adjacent follicles. Management in contact lens wearers
A lid scrub performed the following morning will remove In general, contact lens wearers presenting with parasitic
dead lice and associated debris trapped in the ointment. infestation of the eyelids should be treated in the same
Heavy metal ointments such as yellow mercuric oxide are way as similarly infested non-lens wearers. Paradoxically,
usually prescribed because of their supplementary anti­ contact lenses (soft lenses in particular) serve a protective
microbial efficacy. Pilocarpine gel has been suggested as a function during parasitic eyelash infestation because they
more potent alternative. Treatment should be continued for prevent the cornea from mechanical effects of altered lid
at least 3 weeks, even if early symptomatic relief has been margins and lashes, and prevent toxins and debris from
achieved.6 coming into contact with the cornea.15
If the above measures are unsuccessful, more aggressive It is advisable to cease lens wear during the treatment
in-office therapy may need to be adopted. Vigorous scrubs period, which in severe cases may last up to 1 month.
with a cotton-tipped applicator soaked in alcohol or ether, Contact lenses can theoretically serve as a vector for trans-
performed weekly for 3 weeks, may bring the condition mission of mites, lice, nits or other potentially toxic or aller-
under control.6 genic by-products of the infestation process. The probability
Patients experiencing symptoms of dryness due to demo- of such vectorial transmission increases if the patient is
dectic infestation of the skin should be cautioned against partially non-compliant by, for example, failing to surfac-
the use of facial oils, and should be advised to wash the tant clean and/or manually rub their lenses following lens
affected areas daily with soap.6 removal. An intense cleaning regimen is indicated for
Practitioners should be alert to the possibility of alarming patients with eyelash infestations. The best modality of lens
patients about the existence of ‘spider-like’ parasites on wear for patients with recurrent parasitic eyelash infesta-
their body. It should be explained that this is a chronic tion is daily disposable contact lenses.
condition that can be kept under control if the patient com- Caroline et al.16 have highlighted the sensitive nature of
plies with the treatment protocol. managing crab lice infestation in that it is primarily a sexu-
ally transmitted disease. They caution that loss to follow-up
Treatment of lice infestation is to be expected in a significant number of patients who
may be too embarrassed to return to their eyecare practi-
The initial course of action is to mechanically remove the tioner for further care of the eyelash infestation or indeed
lice from the lashes with forceps, while visualizing the for further contact lens management.
process using medium to high power on a slit lamp biomi-
croscope. This may be difficult because the lice typically
maintain a tight grasp on the lashes. Heavy infestations Other contact lens-associated
are best removed using cryotherapy (freezing) or argon
laser photoablation. The latter technique effectively slices eyelash disorders
through the lashes; the result is initially unsightly, but the
patient should be reassured that the lashes will quickly
grow to full length. Lice and nits will also be killed by
Insects trapped in eyelashes
application of 20% sodium fluorescein.13 Dead flying insects are occasionally observed on the lid
The patient should be advised to apply yellow mercuric margins, just posterior to the base of the eyelashes. These
oxide ophthalmic ointment twice daily to the lid margins insects perhaps land on the lid margin quite accidentally,
to smother and kill adult lice. This therapy should be con- realize that they have found a soft, moist and succulent
tinued for 2 weeks in order to cover at least one complete environment (the conjunctiva and meibomian secretions),
lice life cycle. Anticholinesterase agents may also be tried. and take measures to anchor themselves in position.
More potent insecticides are seldom used today because of Another possibility is that they quickly become stuck in the
the potential for serious corneal injury. Patients should be oily lipid secretions of the lid margin. A strong reflex blink
warned that symptoms may persist beyond effective eradi- or eye rub by the host may then kill or incapacitate the
cation of lice due to residual lice-induced hypersensitivity insect, which remains in place until physically dislodged.
reactions.13 Figure 7.14 shows an insect trapped on the upper lid
Patients should be referred for treatment of pubic infesta- margin of a soft contact lens wearer who noticed discomfort
tion and other possible sexually transmitted diseases. in her left eye during a holiday in Spain. The patient attrib-
Sexual partners and family members should also be exam- uted the consequent irritation to a split in her contact lens;
ined for eyelash infestation and counselled about the she returned to her practitioner who detected the insect
73
Chapter 7 Part II: Eyelids

on slit lamp examination. Figure 7.15 shows a flying will often attempt to remove the eyelash as well, if it can
insect trapped on the lower lid margin of a rigid contact be located. Examination of the eye following such an inci-
lens patient. dent may reveal evidence of corneal epithelial trauma; if
severe, lens wear should be ceased until the epithelium has
recovered.

Trichiasis
Trichiasis is a condition in which the eyelashes curl inwards
towards the globe (Figure 7.16). This can manifest as a
primary condition or be secondary to entropion (Figure
7.17). Whatever the cause, the result can be discomfort and
persistent abrasion of the cornea by the eyelashes, and in
non-lens wearers this can lead to significant corneal decom-
pensation in the form of a vascular pannus if left untreated
for a significant length of time.2

Figure 7.14 Insect stuck on the upper lid margin just posterior to the row
of lashes. (Courtesy of I DeSchepper, Bausch & Lomb Slide Collection.)

Figure 7.16 Ingrowing eyelash from the lower lid irritating the ocular
surface of a rigid lens wearer. (Courtesy of Brian Tompkins.)

Figure 7.15 Insect stuck on the lower lid margin just posterior to the row
of lashes. (Courtesy of J Prummel, Bausch & Lomb Slide Collection.)

The above cases highlight the importance of thoroughly

examining the lid margins when trying to find the
cause of discomfort that is apparently related to contact
lens wear.

Shedded eyelash entering the eye

The life-cycle of an eyelash is about 5 months, and it takes
about 2 months for a new eyelash to become fully grown.1
Thus, there are frequent opportunities for a shedded eyelash
to enter the eye. In non-lens wearers, an eyelash that enters
the eye typically elicits an intense foreign body discomfort
sensation, which causes increased lacrimation and results
in the lash being flushed out. In contact lens wearers, the
lash may become lodged beneath the lens; this is generally Figure 7.17 Trichiasis resulting from entropion. (Courtesy of Brian
very uncomfortable. The patient will remove the lens and Tompkins.)
74
 Eyelash disorders

Contact lenses can act as a protective buffer against 3. Nichols KK, Foulks GN, Bron AJ, et al. The international
corneal damage – with soft lenses offering more protection workshop on meibomian gland dysfunction: executive
than rigid lenses due to their greater corneal coverage. summary. Invest Ophthalmol Vis Sci 2011;52:1922–9.
However, the cornea can be damaged when lenses are not 4. Faherty B. Chronic blepharitis: easy nursing interventions
being worn, and subsequent lens wear in the presence of for a common problem. J Ophthalmic Nurs Technol
an epithelial trauma is problematic because the epithelial 1992;11:20–2.
breach may render the eye more susceptible to microbial 5. Keys JE. A comparative study of eyelid cleaning regimens in
infection. Inward growing eyelashes should therefore be chronic blepharitis. CLAO J 1996;22:209–15.
treated by one of the following techniques: 6. Edmondson W, Christenson MT. Lid parasites. In: Onefrey
• Epilation – eyelashes are mechanically removed with B, editor. Clinical Optometric Pharmacology and
the aid of forceps. Therapeutics. Philadelphia: Lippincott-Raven; 1992.
• Electrolysis – the eyelash follicle is destroyed by 7. Sengbusch HG, Hauswirth JW. Prevalence of hair follicle
passing an electrical current through a fine needle mites, Demodex folliculorum and D. brevis (Acari:
inserted into the lash root. Demodicidae), in a selected human population in western
• Cryotherapy –the lash follicle is frozen with a nitrous New York, USA. J Med Entomol 1986;23:384–9.
oxide cryoprobe at −20°C.2 8. English FP, Nutting WB. Demodicosis of ophthalmic
concern. Am J Ophthalmol 1981;91:362–6.
9. Heacock CE. Clinical manifestations of demodicosis. J Am
Distichiasis Optom Assoc 1986;57:914–16.
10. Anderson PH, Jones WL. A recalcitrant case of Demodex
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