management of blepharitis and dry eye disease

• Anterior Blepharitis

  • Crusty appearance - a more streptococcal reaction
  • Sticky/oily appearance - the more seborrheic subgroup reaction
  • White circular oily caps - capped meibomian glands
• Staphylococcal blepharitis

  • Caused by: Direct infection
  • Reaction to staphylococcal exotoxin
  • Allergic response to staphylococcal antigen
• Seborrheic blepharitis

  Disorder of the ciliary sebaceous glands of Zies
• Demodex

  Small mites
• MGD/Posterior Blepharitis

  • Opaque nature to the meibomian glands and they leak
  • Should not be thick and opaque
  • The gap in the middle, the atrophy occurs when it is chronic. The meibomian gland death
• Order of Management

  1. Hot compresses

  2. Lid massage

  3. Lid hygiene

  4. Dry eye management - if necessary
• Hot compresses

  • Softening anterior blepharitis crusts (better if wet)
  • Liquefy or soften the contents of obstructed glands (better if dry)
  • ≥40°C is required for approximately 5 minutes
  • Mixed evidence on moist versus dry heat
• Warm cloth

  • Wet facecloth either with warm tap water or popped in the microwave to heat up
  • Multiple cloths can be wrapped around each other to retain heat (known as bundling)
  • Caution with too high a temperature
  • >45°C can cause a thermal burn and corneal deformation on eye rubbing
  • 5 minutes up to twice a day
  • Most cost efficient
• Commercial eye masks

  • More convenient because they are designed for the task
  • Usually go in the microwave or activated with pressure if single use
  • Beads (absorb the heat and then gradually release it over 5-10 mins)
  • Natural grains
  • Hot or cold depending on the use
  • Antibacterial coating on the mask to keep it sterile
  • Removable covers that can be washed
• Massage

  • Not enough just to heat the meibomian glands
  • Removing the obstruction that is now hopefully softened
  • This should allow the normal oils to flow
  • Needs to be done regularly
  • Firm pressure with the fingertips below the lower eyelashes and above the upper
  • Should not be painful
• Lid hygiene

  • Physical removal of debris from the eyelashes
  • Removes bacteria
  • Various options - water, gels, wipes
  • Mixed literature for which method is best
• Lid hygiene is widely considered an effective mainstream therapy for MGD and blepharitis
• Despite the fact that various professional organisations suggest ways to clean the eyelids, to date, there are no universally accepted guidelines for lid cleansing and peer-reviewed evidence for such advice is lacking
• Water

  • Cool boiled water - don't risk burning but sterile
  • With added baby shampoo
  • With added bicarbonate of soda
  • Important to use clean cotton bud/pad dipped in the solution
• Baby shampoo

  • Ration of 10:1, cooled boiled water to baby shampoo
  • Literature shows an improvement in symptoms, crusting and lash loss
  • But worsening in MG capping and possible reduction in goblet cell function
• Bicarbonate of soda

  • Gentle abrasive
  • Mechanical removal of crusts
  • ¼ teaspoon mixed with cooled boiled water
• Pre-prepared solutions

  • Saves mixing solutions at home
  • More expensive
  • Use alongside cotton pad
  • Ingredients - Blephasol (micelle solution, preservative free)
  • OcuSoft (foam cleanser, contains preservative)
• Lid wipes

  • Most expensive option
  • Easiest option
  • Single use wipes
  • The main point with lid hygiene is the mechanical action, rather than the agent used
• Antibiotics

  • Staphylococcal and seborrheic blepharitis can be managed with a short course of topical antibiotics
  • Lid hygiene should continue after completion of the course
• Chloramphenicol

  • 1% chloramphenicol ointment
  • Rubbed into the eyelid margin twice a day for 1 week (dosage and duration can vary, check local guidelines)
  • Broad spectrum
  • Bacteriostatic by inhibiting protein synthesis
  • No contact lens wear during treatment, safety in pregnancy has not been established, not for use when breast-feeding
  • Can cause transient blurring and stinging
• Dry eye disease management

  • Wide range of symptoms - lacrimation, discomfort, burning, itching
  • Signs - reduced tear production, reduce tear stability
  • Includes managing anterior blepharitis/MGD as appropriate
  • Tear substitutes - replacing the component that is lost (drops, gels, ointments)
• Retention time

  • The longer the retention time the better as that will relieve symptoms for longer
  • But to achieve a longer retention time usually involves a higher viscosity which can have issues
• Viscosity

  • The quality or state of being viscous (= thick and sticky and not flowing easily)
  • Corresponds to the concept of 'thickness'
  • If an eye drop has a low viscosity, it will be washed away very quickly e.g. saline
• Viscosity-enhancers

  • Increasing tear film thickness
  • Protecting against corneal/conjunctival desiccation
  • Improving goblet cell density
  • And therefore, improving patient symptoms
• Low viscosity

  • Easy to instil
  • Doesn't blur vision
  • Shorter retention time
  • Needs frequent use to keep symptoms at bay
• High viscosity

  • Long retention time
  • Perfect for overnight use
  • Can be trickier to instil
  • Can blur vision
  • Debris can gather on lashes and eyelids
  • Reduced compliance and patient satisfaction
• Viscosity enhancers in eye drops

  • Carboxymethyl cellulose (CMC)
  • Hyaluronic acid (HA)
  • HP-guar
  • Hydroxypropyl methylcellulose (HPMC) aka Hypromellose
  • Polyvinyl alcohol (PVA)
  • Polyethylene glycol
• Lipids in eye drops for MGD

  • Castor oil
  • Mineral oil
  • Soybean oil
  • Sea buckthorn seed oil
  • Liposomal spray
• Ingredients in gels

  • Carbomer 940
  • Carboxymethylcellulose (higher concentration)
• Ingredients in ointments

  • Liquid paraffin
  • Wool fat (lanolin)
  • White soft paraffin
  • Mineral oil
• There is no evidence that one eye drop is better than the other
• Although there are scores of formulations and products available, which vary by geographic region, there does not appear to be any substantial difference in effectiveness among them
• Preservatives

  • Prevents microbial growth in the bottle
  • Maintains the sterility of the solution once opened
  • Cheaper than single dose vials
• Detergent preservatives

  • Benzalkonium chloride (BAK)
  • Polyquaternium-1 (Polyquad)
  • Ruptures the outer membrane of the micro-organism
  • BAK was traditionally used but has been shown to be toxic to the ocular surface
  • Polyquad is derived from BAK and is considered less toxic, as while it is attracted to bacteria it is rejected by corneal epithelial cells
• Oxidation preservatives

  • Sodium chlorite (Purite)
  • Sodium perborate (GenAqua)
  • Alters the lipid membrane of the microbes
  • Reduced toxicity to ocular surface
  • Able to keep concentrations low to avoid toxicity
• Complications of preservatives

  • Long term use of a preserved drop can lead to Conjunctivitis Medicamentosa
  • Symptoms - irritation, stinging, burning, photophobia, ocular redness, blurred vision, lid swelling
  • Signs - usually diffuse punctate staining of cornea/conjunctiva, tear film instability
  • Switching the patient to a preservative free drop should lead to a resolution of the problem
  • Cold compresses can also improve symptoms
  • Avoid the preservative in the future
  • Need to weigh up the benefits versus the complications