Tarsal Plate Rotation for Trichiasis: Indications, Technique and Aftercare

OPHTHALMOLOGY · OPHTHALMIC SURGICAL PROCEDURES · STUDENT STUDY NOTES

Tarsal plate rotation is an eyelid operation that turns an in-rotated, lash-bearing eyelid margin away from the ocular surface. In trachoma-endemic settings it is used to treat upper-lid trachomatous trichiasis (TT), the late scarring complication of repeated ocular Chlamydia trachomatis infection. The operation aims to stop lashes abrading the cornea, relieve pain and protect vision. The two principal procedures are bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR, also called the modified Trabut procedure).

Learning objectives

After this lesson, you should be able to:

• Explain how trachoma-related scarring causes cicatricial entropion and trichiasis.
• Apply the WHO simplified definitions of trachoma and distinguish TT from other causes of trichiasis.
• Describe the goals, indications, assessment and broad principles of tarsal plate rotation surgery.
• Distinguish BLTR from PLTR and describe how contemporary evidence informs technique selection.
• Recognise appropriate temporary management, postoperative review, recurrence and complications.
• Identify the emergency-care priorities when lashes injure the cornea or the patient presents with a postoperative problem.

At a glance

Why trachomatous trichiasis matters

Trachoma is a chronic conjunctival infection caused by ocular strains of Chlamydia trachomatis. It spreads within communities through close contact with ocular or nasal secretions, contaminated items and eye-seeking flies. Repeated episodes of infection and inflammation can scar the upper tarsal conjunctiva. The scar contracts, distorts the tarsal plate and turns the eyelid margin inward. One or more eyelashes then touch the eye and scrape the corneal epithelium with blinking.

Persistent lash contact causes foreign-body sensation, tearing, redness, pain and photophobia. Repeated epithelial injury may lead to corneal abrasion, secondary infection, ulceration, vascularisation, opacity and irreversible visual impairment. The patient may pluck lashes (epilation) for temporary relief, so a careful history can reveal disease even if no lash is touching the globe at the moment of examination.

In trachoma programmes, lid surgery is the S in the WHO SAFE strategy: Surgery for trichiasis, Antibiotics to clear infection, Facial cleanliness and Environmental improvement. The strategy addresses both the individual’s risk of corneal damage and the community transmission conditions that sustain trachoma. Tarsal rotation treats the scarring consequence; it is not itself antibiotic treatment for active infection.

Relevant eyelid anatomy and the mechanical principle

The eyelid can be considered as two functional layers, or lamellae. The anterior lamella includes skin, orbicularis muscle and the eyelash-bearing margin. The posterior lamella includes the tarsal plate and palpebral conjunctiva. The upper tarsus is a dense connective-tissue plate that provides structural support. The levator aponeurosis attaches to the tarsus and raises the upper lid; the orbicularis closes it. The margin contains the eyelashes and their follicles.

In cicatricial entropion, scarring on the posterior surface shortens and distorts the lid, rotating the margin and lashes inward. Rotation surgery repositions the tarsal segment and its lash-bearing edge so the lashes point away from the cornea. The desired outcome is a stable, smooth lid margin with lashes no longer touching the globe, comfortable closure and acceptable eyelid contour. The procedure is not simply lash removal: epilation removes lashes temporarily but leaves the underlying in-turning unchanged.

When examining the upper lid, assess the lashes, lid margin, conjunctival scarring and cornea. Eversion of the upper lid is a clinician skill and should be performed gently by someone trained to do so. Students should understand what is being assessed, not practise forceful manipulation on a painful or injured eye.

WHO simplified trachoma grading and TT definitions

The WHO simplified grading system uses five signs. The 2018 WHO expert meeting updated the TT definition to specify the upper lid and to include evidence of recent epilation of in-turned upper-lid lashes.

TT can be described as minor when five or fewer lashes touch the globe and major when more than five touch, a commonly used programme and research distinction. The WHO definition of TT itself is not restricted to a particular lash count. Do not confuse this severity description with an automatic decision about surgery; management takes account of symptoms, corneal risk, entropion, patient preference, access to follow-up and local programme guidance.

Symptoms, signs and examination

Ask about foreign-body sensation, pain, tearing, redness, photophobia, blurred vision, duration, previous treatment, prior lid surgery, epilation and the frequency with which lashes are removed. Ask whether the patient can return for postoperative review and whether practical barriers—travel, work, childcare, cost or family support—might affect access. These issues can delay care, especially where surgical services are distant.

Record visual acuity in each eye before any procedure, using the method available and documenting limitations. Examine the eyelids and lashes in good illumination with magnification when possible. Look for lashes touching the globe or cornea, conjunctival scarring, upper-lid entropion, lid contour, blink and closure. Examine the cornea for epithelial defects, punctate staining, infiltrate, ulceration, pannus and opacity; assess the anterior segment and other causes of reduced vision when equipment and expertise allow.

Ask about previous trachoma, residence in or travel to an endemic area, household exposure, childhood eye disease and prior antibiotic campaigns. Trachoma remains a clinical diagnosis in many settings. Where upper-lid trichiasis is present but there is little or no evidence of past or current trachoma, a trained clinician should consider alternative causes rather than labelling every in-turned lash as TT.

Important alternative causes

• Non-trachomatous cicatricial entropion: may follow mucous membrane pemphigoid, Stevens–Johnson syndrome, chemical injury, burns, trauma, chronic inflammation or previous surgery.
• Involutional entropion: age-related horizontal lid laxity and retractor changes, usually requiring a different surgical plan.
• Distichiasis or metaplastic lashes: abnormal lashes arise from atypical sites or glands and may touch the cornea without the usual scarred-lid mechanism.
• Trichiasis without entropion: one or more misdirected lashes may touch the eye while the lid margin is not globally rotated inward.
• Lower-lid trichiasis: the updated WHO programme definition of TT refers to upper-lid disease. Lower-lid lash contact still needs care, but the operation is selected according to the anatomical cause.

This distinction matters because a tarsal plate rotation designed for upper-lid cicatricial entropion is not a universal treatment for every eyelash rubbing on the eye.

Indications, goals and referral

Rotation surgery is considered for upper-lid trachomatous trichiasis when lash contact threatens the ocular surface, especially when entropion is present. WHO advises measuring visual acuity and referring people with TT to an eye unit; management may include eyelid surgery or regular epilation. Surgery is the definitive mechanical correction for appropriate candidates, while epilation is a temporary option for patients awaiting surgery, declining it or unable to access it, with follow-up because lashes regrow.

The goals are to stop lashes rubbing on the globe, protect the cornea from ongoing injury, reduce discomfort and help preserve remaining sight. Surgery cannot restore sight already lost from dense corneal opacity, nor does it treat cataract, glaucoma, retinal disease or active chlamydial infection by itself. Patients need an honest explanation of expected benefit, limitations, recurrence risk and the possibility of further treatment.

Referral should be prompt when lashes are touching the cornea, when there is pain or photophobia, when vision is reduced, or when there is corneal epithelial damage. A corneal ulcer, infiltrate, marked visual loss, severe inflammation, inability to close the eye, or a compromised only seeing eye warrants urgent specialist assessment. The precise urgency is determined by the clinical findings and local service capacity.

Preoperative assessment, counselling and preparation

1. Confirm the diagnosis and side. Document which lid and eye are affected, the number and distribution of lashes, whether a lash touches the globe, whether there is evidence of epilation, entropion severity and signs of conjunctival scarring. Consider alternative aetiologies if the history and findings do not fit trachoma.
2. Assess the ocular surface and vision. Record visual acuity in both eyes and document corneal staining, abrasion, ulceration, opacity and anterior segment findings. Determine whether other eye disease also needs treatment.
3. Assess fitness and practical suitability. Review relevant medical conditions, medicines, allergies, bleeding history and previous eyelid surgery. A surgeon decides whether local anaesthesia and the proposed setting are suitable. Confirm that safe sterile equipment, trained personnel and postoperative review are available.
4. Discuss options and obtain informed consent. Explain surgery, temporary epilation, benefits, risks, postoperative care, possible recurrence, cosmetic change, the need for follow-up and the potential for additional procedures. Ask about the patient’s preferences, concerns and ability to return. Use language and an interpreter the patient understands.
5. Plan for the patient, not only the lid. Agree on transport and support if needed, a contact pathway for urgent problems, and follow-up that is realistic for the patient’s community. Consider barriers that may particularly affect women or people living far from eye-care services.
6. Use safe surgical systems. In the operating setting, confirm patient identity, correct eye and operation; complete a site check and team time-out. Use infection-prevention and instrument-processing procedures required by the service.

Operation principles and the two main techniques

Both procedures are specialist operations for upper-lid TT. Their common mechanical aim is outward rotation of the lash-bearing lid margin. The incision plane differs. Selection depends on the surgeon’s training, programme guidance, case features and local protocols. WHO’s 2024 third edition is the current global training reference and incorporates both the BLTR and PLTR approaches, with expanded postoperative-care guidance.

Do not mix these operations up with a lower-lid anterior lamellar recession, a Wies procedure, lateral tarsal strip, simple epilation, cryotherapy or electrolysis. These address different eyelid problems, anatomical layers or lash patterns. If the cause is not trachomatous upper-lid cicatricial entropion, an ophthalmologist selects the appropriate procedure.

Broad stages for learning—not operative instructions

1. Preparation and anaesthesia: the patient, eye and planned correction are reconfirmed, the operative field is prepared and the trained surgeon provides appropriate anaesthesia.
2. Exposure and stabilisation: the upper lid is positioned and stabilised so the surgeon can assess the tarsal plate and plan a controlled correction. The cornea is protected throughout.
3. Lamellar/tarsal correction: according to the chosen operation, the surgeon makes the relevant tarsal division in the appropriate plane and releases the scarring forces sufficiently to rotate the lash-bearing edge outward.
4. Rotation and fixation: the distal tarsal segment and lid margin are positioned to achieve an even correction across the lid. Sutures hold the corrected position. The surgeon checks the contour and lash direction during the procedure.
5. Wound care: haemostasis is confirmed, the wound and lid margin are checked, prescribed ointment is applied and the eye is protected with a dressing according to local protocol.
6. Recovery and review: the patient receives pain-control and home-care advice, a next-day appointment with the operating surgeon and a route for urgent return if symptoms worsen.

The critical technical endpoint is not simply “the lid looks turned out.” The whole lash-bearing margin must be corrected evenly without excessive eversion, notching, irregular contour or impaired closure. Specific incision measurements, instrument handling, suture placement and correction of technical errors belong in supervised hands-on training using the WHO manual.

Postoperative care and review

The operating service gives patient-specific instructions. The WHO manual emphasises assessment on the first postoperative day by the surgeon who performed the operation. A typical pathway includes keeping the dressing in place until the instructed review, then examination of wound status, swelling, lash position, eyelid contour and closure. Some early swelling is expected; the surgeon determines whether the correction is appropriate.

A correctly rotated eyelid may show slight early overcorrection because postoperative swelling and settling alter the appearance. The operating surgeon assesses this alongside corneal protection and lid closure. If there is clear undercorrection or overcorrection, WHO guidance calls for prompt surgeon review and may require same-day correction. Patients and students must not attempt to remove sutures, reposition the lid or treat an unsatisfactory result themselves.

• Use only the prescribed ointment, drops and oral medicines; avoid unprescribed or leftover eye medication.
• Keep the dressing and wound clean and follow instructions about when it may be removed.
• Avoid rubbing, pressing or pulling the operated lid. Do not pluck lashes or manipulate sutures unless the treating clinician advises it.
• Attend day-one review even if pain is modest; early assessment can identify wound problems or inadequate correction.
• Return urgently for increasing pain, worsening redness or swelling, purulent discharge, fever, excessive bleeding, sudden reduced vision or inability to close the eye.
• Continue longer-term review as scheduled. Programmes should monitor postoperative trichiasis and audit outcomes, often at six months, so recurrence is identified and surgical quality can be improved.

Outcomes, recurrence and evidence

Surgery usually improves lash position and can relieve the continuing mechanical insult, but recurrence is a recognised outcome rather than proof that the initial operation was futile. Postoperative TT (PTT) means that upper-lid lashes again touch the globe or that the patient has recurrent disease requiring repeat surgery. Recurrence may be minor or major; even a small number of lashes can injure a vulnerable cornea.

Evidence comparing BLTR and PLTR is nuanced. A large Ethiopian randomised trial of 1,000 people found less postoperative TT after PLTR than BLTR at one year, and a four-year follow-up found recurrence in 13.6% of PLTR versus 22.2% of BLTR eyes. A 2024 randomised trial comparing PLTR with two BLTR incision heights found no significant difference in postoperative TT between PLTR and standard-height BLTR, while the modified higher BLTR incision had worse recurrence; this illustrates that technical execution and the exact method matter. A 2025 programme-based comparison also found lower one-year recurrence in the PLTR group, but surgeons used their preferred method and the groups were not randomly assigned, so that result has different limitations from a randomised trial.

WHO’s 2024 third-edition training manual covers both procedures and updates postoperative care. Current programme guidance favours teaching PLTR to new TT surgeons, while allowing surgeons already trained and competent in BLTR to continue their preferred method. Students should learn this practical recommendation and also understand that outcomes depend on operator skill and implementation; a trial result is not a guarantee for an individual patient.

Factors associated with recurrence or unfavourable outcomes include severe baseline entropion or trichiasis, ongoing conjunctival inflammation, residual lash contact, imperfect or uneven rotation, healing and scarring, surgeon experience, follow-up access and delayed recognition of PTT. Recurrence can often be managed by an eye-care surgeon with repeat surgery or another suitable treatment; it should not be dismissed as “normal.”

Complications and their recognition

Emergency-care approach

For an emergency clinician, the priority is to determine whether there is immediate threat to vision or the patient’s general health, protect the ocular surface and obtain appropriate ophthalmology support. A patient with active TT and corneal injury needs prompt eye-unit referral; a patient following recent surgery with severe pain, falling vision, progressive swelling, purulent discharge, wound separation or inability to close the eye should receive urgent ophthalmic assessment.

1. Assess first: record visual acuity in each eye when feasible, symptoms and onset, vital signs if unwell, prior surgery or epilation, medications and relevant history.
2. Inspect without pressure: observe the lid position and lashes and assess visible corneal redness or opacity with the available light. Do not press on a compromised globe, pull at the wound, remove sutures or manipulate a recently operated eyelid.
3. Protect and refer: for suspected corneal ulcer or serious postoperative infection, arrange urgent ophthalmology review and follow local emergency protocols. Avoid routine patching of an infected cornea unless a specialist directs it.
4. Do not delay for programme classification: acute corneal pain with reduced vision, a white spot/infiltrate, photophobia or trauma is an urgent clinical problem regardless of whether the trachoma grade is known.
5. Support the patient: explain why follow-up matters, make referral practical and document the patient’s only seeing eye, barriers to travel and contact arrangements.

Immediate red flags: sudden reduction in vision; severe or increasing eye pain; a corneal ulcer or infiltrate; marked photophobia; progressive postoperative swelling or redness; fever; purulent discharge; heavy bleeding; poor eyelid closure; or new corneal haze.

Counselling and prevention after surgery

Explain that rotation corrects the position of the lid but does not remove the history of trachoma or guarantee that lashes will never recur. Patients should know the warning symptoms, the timing of their next review and how to contact the service. Where a lash remains or recurs, timely review can prevent prolonged corneal damage.

In trachoma-endemic communities, individual counselling can reinforce facial cleanliness and appropriate antibiotic services under national elimination programmes, along with improved water and sanitation. Antibiotic selection and mass-treatment schedules belong to national or local protocols; surgery does not replace them. Patients should not be blamed for disease linked to poverty, crowded living conditions or lack of access to clean water.

Practical planning improves attendance: agree on transport, review location and timing; provide clear verbal and written instructions; use interpreters when needed; and involve a trusted support person with consent. Ask whether work, care duties, cost or distance may make follow-up difficult and connect the patient to available community eye-care support.

Clinical cases

Case 1: lashes rubbing, no corneal ulcer

A 46-year-old reports chronic tearing and foreign-body sensation. On lid examination, three upper-lid lashes touch the cornea and white scars are visible on the everted tarsal conjunctiva. Visual acuity is reduced in that eye.

Discussion: this fits minor upper-lid TT in the appropriate clinical setting. Measure and document vision, examine the cornea for epithelial damage or opacity and refer to an eye unit for treatment options including surgery or regular epilation. A low lash count does not mean the cornea is safe, and reduced vision needs assessment for other causes as well.

Case 2: epilation hides the lash contact

A patient says they pluck lashes from one upper lid every week. No lash touches the globe during today’s examination, but scarring and in-turning of the upper lid are present.

Discussion: recent epilation of in-turned upper-lid lashes is included in the WHO TT definition. Clarify that the plucked lashes were in-turned and came from the affected upper lid; epilation offers temporary relief but does not correct the scarred lid position. Refer for appropriate eye-care assessment.

Case 3: red painful eye after lid surgery

On the day after tarsal rotation surgery, the patient has mild swelling but reports rapidly increasing pain, reduced vision and photophobia.

Discussion: mild swelling can occur, but increasing pain and reduced vision are warning symptoms. The operating surgeon should assess wound and lid correction and examine the cornea. Emergency staff should not remove sutures or forcefully manipulate the lid.

Case 4: upper-lid trichiasis without signs of trachoma

A patient with a history of severe mucosal blistering disease has upper-lid scarring and lash contact, but no relevant exposure history and no typical trachomatous signs.

Discussion: trichiasis is present, but the cause may be a cicatrising ocular-surface disorder rather than trachoma. Ophthalmology assessment is important because disease activity, the ocular surface and procedure choice differ. Do not apply a trachoma programme label or operation automatically.

Case 5: postoperative lash contact at follow-up

Several weeks after surgery, the patient still has two lashes contacting the cornea and has started epilating them again.

Discussion: this is possible postoperative TT and requires reassessment. Check the cornea and vision, document the location and extent, and refer to an appropriately trained surgeon. Do not reassure the patient that recurrent lash contact is harmless.