By: Paul M. Karpecki, OD, FAAO
Clinical Director – PECAA
The eyelids may be the key to most dry eye disease. This comment was first emphasized in the International Task Force’s Dysfunctional Tear Syndrome (DTS) Delphi Approach Report1 where it was recommended that each time Dry Eye Disease or DTS was diagnosed one must determine if lid margin disease is present or not. It makes sense from a slit lamp order of examination perspective but also realizing the importance of blepharitis in dry eye disease be it anterior blepharitis affecting the eyelashes and eyelids or posterior blepharitis as in meibomian gland dysfunction (MGD).
Diagnosing the Types of Anterior Blepharitis
Blepharitis is simply defined as inflammation of the eyelids. Because of this broad definition, there are many types of blepharitis ranging from angular blepharitis to periorbital eczema in cases of atopic keratoconjunctivitis. We’re going to focus on three of the most common anterior blepharitis types and discuss key symptoms, signs and treatment options. It’s imperative to make the distinction so you have the correct diagnosis because effective treatments are relatively different for each type.
Staphylococcus bacteria is ubiquitous on the human body. For multifactorial reasons, certain patients get an overabundance of these bacteria leading to complaints of mattering, debris on the lashes, irritated or swollen eyelids and eyelash margins, hordeola development, eyelid ulceration in severe cases, and even conjunctivitis. The classic appearance of staph blepharitis is described as yellowish debris or collaretes, matter or discharge2 and erythema and hyperemia of the eyelid margins. This condition can lead to damage of the eyelid margins including ductal metaplasia, tear film instability and even infections including primary and post-surgical. Treatment for staph blepharitis should include eyelid hygiene involving commercial foam surfactant cleansers (e.g. Lid Scrub Plus or SteriLid), hypochlorus acid based cleansers for more severe forms (Avenova – NovaBay or HypoChlor-OcuSoft) and commercial warm compress masks (Bruder Healthcare). Topical antibiotics are effective in acute cases where the bacterial component is the primary cause.3 In chronic cases, the condition becomes more inflammatory and therefore combination agents (antibiotic + steroid drops and ointments) seem to work well4 in treating the infection and inflammation of the disease. 5 In office mechanical treatments (BlephEx) are often implemented to get the bacterial colonization to a proper level. Longer term maintenance is best achieved with commercial eyelid cleansers used routinely and patients be educated about the chronic nature of this disease and that there is no known cure.6
Demodex blepharitis becomes more prevalent as we age and studies have shown that the majority of blepharitis in patients above age 60 is caused by demodex.7 Patients with rosacea are also much more likely to experience demodex blepharitis. The average healthy person without blepharitis has over 2000 demodex mites on their body at any given time.8 Overabundance results in a presentation of clear ‘sleeves’ and debris that appear to primarily be focused at the base of the lashes. The most common complaint of patients with demodex blepharitis is itching of the lid margins and in longstanding cases, madarosis or loss of lashes. But perhaps the main way that it has traditionally been diagnosed is when it is unresponsive to other treatments.9 Hopefully we change that an are able to make the diagnosis on initial presentation. Treatment requires the use of tea tree oil based products and the most effective treatments are usually approaching a concentration of 50%. There are a number of commercial in-office ‘kits’ available to treat this form of blepharitis and appear to be superior or at least less uncomfortable than creating a 50% tea tree oil solution yourself, which may also have many unwanted toxins. In addition to the tea tree oil, they often contain a brush for applying the solution and one or the other side for scrubbing the lid margins. One could also use a mechanical in office cleaner (BlephEx). This treatment should be performed after applying topical anesthetic to the eyelid margins, waiting 3-5 minutes and repeat the anesthetic + treatment. Most patients require multiple treatments and should be advised to use the other products in the kits at home each night to minimize the in-office treatments required. Patients will typically mention burning or tingling during or after the procedure. Also be sure that during treatment, the patient keeps their eyes closed at all times to avoid a potential corneal abrasion. High concentrations or impurities in the tea tree oil can be uncomfortable for patients so companies have found novel ways to minimize that concentration or the toxins that could be present. The OcuSoft Demodex Kit adds buckthorn seed oil to the tea tree oil as both ingredients have been shown to be effective against demodex mites. Cliradex (BioTissue) isolates the active ingredient in tea tree oil, known as 4-Terpineol in it’s Cliradex Complete Kits. Once again this form of blepharitis is also chronic and patients must expect it will likely return but hopefully not for months or years. Maintenance may help and can involve Cliradex pads periodicaly, lid hygiene with surfactant or hypochlorus acid cleansers and some commercial cleansers such as Oust and SteriLid have a small percentage of tea tree oil in them – not likely sufficient for a primary treatment but perhaps for maintenance after the in-office procedure.
A third form of blepharitis is that of a dematological conditions known as seborrheic blepharitis. This is often described as oily or greasy eyelid deposits, mild conjunctival injection, and inferior punctate epithelial erosions, but rarely any effects on the eyelashes.10 Patients with this form of blepharitis will often present with complaints that focus on the eyelids themselves including irritation, redness and occasionally itching. This condition is best treated with a topical corticosteroid such as triamcinolone cream 0.1% or if the doctor is concerned about the patient getting the product in the eyes, an ophthalmic steroid such as lotemax ointment can be prescribed. Patients should be told to use corticosteroids on the eyelids for no more than 2-3 weeks. Fluorinated steroids for example have been shown to cause eyelid thinning or discoloration with long-term use.11 Once again this form of blepharitis is also chronic and will return. Patients may be able to keep it maintained with commercial lid scrub surfactant cleansers used daily. What is interesting is that each of these forms of blepharitis has a different appearance in presentation. Each also has a different approach to treatment ranging from antibiotic and antibiotic/steroid combination therapy for bacterial blepharitis, to tea tree oil based products for demodex to topical corticosteroids for dermatological forms of blepharitis such as seborrhea. Maintenance treatments (lid hygiene) are similar among the groups yet various options exist depending on presentation and severity. Finally it is important for patients to understand that blepharitis, like arthritis is a condition that cannot currently be cured.12 But like arthritis, if under the good care of a physician and with good compliance, patients can go months or years with few symptoms. Understanding the types of anterior blepharitis in presentation and treatment will better help you manage this common ocular surface disease that affects millions of patients.
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11. Shlivko IL, Kamensky VA, Donchenko EV, Agrba P. Morphological changes in skin of different phototypes under the action of topical corticosteroid therapy and tacrolimus. Skin Res Technol. 2014 May;20(2):136-40
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