Sticky/oily appearance - the more seborrheic subgroup reaction
White circular oily caps - capped meibomian glands
Staphylococcal blepharitis
Caused by: Direct infection
Reaction to staphylococcalexotoxin
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
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