Treatment and long-term follow-up of distichiasis, with special reference to the Friesian horse: a case series

Distichiasis: An update on etiology, treatment and outcomes

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.

Whole genome sequencing identified a 16 kilobase deletion on ECA13 associated with distichiasis in Friesian horses

BACKGROUND

Distichiasis, an ocular disorder in which aberrant cilia (eyelashes) grow from the opening of the Meibomian glands of the eyelid, has been reported in Friesian horses. These misplaced cilia can cause discomfort, chronic keratitis, and corneal ulceration, potentially impacting vision due to corneal fibrosis, or, if secondary infection occurs, may lead to loss of the eye. Friesian horses represent the vast majority of reported cases of equine distichiasis, and as the breed is known to be affected with inherited monogenic disorders, this condition was hypothesized to be a simply inherited Mendelian trait.

RESULTS

A genome wide association study (GWAS) was performed using the Axiom 670 k Equine Genotyping array (MNEc670k) utilizing 14 cases and 38 controls phenotyped for distichiasis. An additive single locus mixed linear model (EMMAX) approach identified a 1.83 Mb locus on ECA5 and a 1.34 Mb locus on ECA13 that reached genome-wide significance (pcorrected = 0.016 and 0.032, respectively). Only the locus on ECA13 withstood replication testing (p = 1.6 × 10- 5, cases: n = 5 and controls: n = 37). A 371 kb run of homozygosity (ROH) on ECA13 was found in 13 of the 14 cases, providing evidence for a recessive mode of inheritance. Haplotype analysis (hapQTL) narrowed the region of association on ECA13 to 163 kb. Whole-genome sequencing data from 3 cases and 2 controls identified a 16 kb deletion within the ECA13 associated haplotype (ECA13:g.178714_195130del). Functional annotation data supports a tissue-specific regulatory role of this locus. This deletion was associated with distichiasis, as 18 of the 19 cases were homozygous (p = 4.8 × 10- 13). Genotyping the deletion in 955 horses from 54 different breeds identified the deletion in only 11 non-Friesians, all of which were carriers, suggesting that this could be causal for this Friesian disorder.

CONCLUSIONS

This study identified a 16 kb deletion on ECA13 in an intergenic region that was associated with distichiasis in Friesian horses. Further functional analysis in relevant tissues from cases and controls will help to clarify the precise role of this deletion in normal and abnormal eyelash development and investigate the hypothesis of incomplete penetrance.

A description of blend electrolysis for treatment of canine distichiasis: 78 cases (2012-2017)

OBJECTIVE

To describe a population of dogs treated with blend electrolysis for distichiasis at The Royal Veterinary College and report the complications seen.

METHODS

In part 1, records were reviewed from 2012 to 2017 and a population of 78 dogs with distichiasis treated using blend electrolysis (Sterex SX-B blend epilator) analysed. In part 2, 18 dogs treated with blend electrolysis were re-examined prospectively by a diplomate of the European College of Veterinary Ophthalmologists (ECVO).

RESULTS

In part 1, brachycephalic breeds accounted for 62 per cent. English bulldog was the most common breed (42 per cent). In this population, 88 per cent of dogs were successfully treated with one treatment of electrolysis (successful treatment defined as resolution of clinical signs). Forty-five dogs had recurrent distichia on follow-up, mostly fine distichia without clinical discomfort. Twelve per cent required repeat electrolysis. Complications were infrequent: five dogs had scarring or hypopigmentation of the eyelid margin. In part 2, 18 dogs were re-examined. Ten had distichia recurrence, six had eyelid scarring and five had depigmentation associated with electrolysis. Two dogs had occasional clinical signs thought to be related to distichiasis. All owners perceived their dogs' ocular comfort to be improved following blend electrolysis.

CONCLUSIONS

Brachycephalic breeds, most notably English bulldogs, are over-represented in this population. Blend electrolysis appears an effective treatment for resolution of clinical signs.

Genetics of Equine Ocular Disease

Horses perform in a variety of disciplines that are visually demanding, and any disease impacting the eye has the potential to threaten vision and thus the utility of the horse. Advances in equine genetics have enabled the understanding of some inherited ocular disorders and ocular manifestations and are enabling cross-species comparisons. Genetic testing for multiple congenital ocular anomalies, congenital stationary night blindness, equine recurrent uveitis, and squamous cell carcinoma can identify horses with or at risk for disease and thus can assist in clinical management and breeding decisions. This article describes the current knowledge of inherited ocular disorders.

Genetic Testing in the Horse

Genetic testing in horses began in the 1960s, when parentage testing using blood group markers became the standard. In the 1990s, parentage testing shifted from evaluating blood groups to DNA testing. The development of genetics and genomics in both human and veterinarian medicine, along with continued technological advances in the last 2 decades, has helped unravel the causal variants for many horse traits. Genetic testing is also now possible for a variety of phenotypic and disease traits and is used to assist in breeding and clinical management decisions. This article describes the genetic tests that are currently available for horses.

Evaluation of partial tarsal plate excision using a transconjunctival approach for the treatment of distichiasis in dogs

PURPOSE

To evaluate the clinical outcome, possible complications, and recurrence rate of distichiasis in dogs treated with partial tarsal plate excision (PTPE) technique using a transconjunctival approach.

METHODS

Retrospective study including 17 client-owned canine patients affected with distichiasis and presenting with associated clinical signs (ie, blepharospasm, epiphora, chronic keratoconjunctivitis, or corneal ulceration) that underwent surgical removal of the aberrant lashes using a PTPE technique between January 2018 and February 2019. Data collected included breed, age, sex, affected eyelid(s), number of distichia, and tear film breakup time (TBUT). Resected cilia-bearing tarsoconjunctival strips were submitted for histopathological analysis.

RESULTS

Thirty eyes (52 eyelids) from 17 dogs were included in the study. The median age was 688 days (range 118-4243 days). A successful outcome, defined as complete resolution of clinical signs attributable to the distichia, occurred in all eyes after a single procedure, with a mean follow-up time of 239 days (range 69-480 days). Appearance of new distichia occurred in 14/30 eyes (46.3%), and of these, three eyes needed a new PTPE procedure. Recurrence of the distichia only occurred in one eye (3.3%) which was asymptomatic. Following surgery, TBUT decreased below the normal value in 7/24 eyes (29.1%) although none developed clinical signs of qualitative tear film deficiency. Post-operative complications included trichiasis and cicatricial entropion, which developed in two eyes (6.6%), and these were successfully managed with corrective eyelid surgery.

CONCLUSIONS

Partial tarsal plate excision, using a transconjunctival approach, had an excellent clinical outcome with a low incidence of complications.