Article Date: 8/1/2007

Blepharitis Triggers Inflammatory NSC

Blepharitis Triggers Inflammatory NSC

A patient's blepharitis rains dead Staph cells onto the ocular surface, resulting in an inflammatory case of nonspecific conjunctivitis.

By Eric D. Donnenfeld, M.D., F.A.C.S.

Nonspecific conjunctivitis (NSC) has many potential causes — fatigue and strain, environmental dryness and pollutants, wind and dust, temperature and radiation, poor vision correction, contact lens use, computer use and dry eye syndrome — just to name a few.

I'll add one more cause: an all-out war against dead cells. It sounds like a classic zombie film, but it's actually a classic cause of nonspecific conjunctivitis.

It occurs when a patient's lid disease causes mild conjunctivitis, and dead Staphylococcal bacteria from the lids fall onto the ocular surface. The cells trigger an inflammatory hypersensitivity reaction on the already irritated eyes. This inflammatory "war" against the dead cells calls for a dual-action drug to combat inflammation and stamp out the potential for any living Staph bacteria.

Patients with nonspecific conjunctivitis may present with redness of the conjunctiva and lid edges, as well as swelling, burning or foreign-body sensation.

Dual Causes Call for Dual Treatment

Aside from allergy, the combined causes of inflammation and infection are probably the most common origins of conjunctivitis. In fact, this combination is more common than all types of infection combined. We diagnose this combination as NSC and treat it with combination drugs that address both components.

Why is NSC so common? The concentration of mast cells in the conjunctiva and the eyelids makes them prime targets for hypersensitivity reactions and inflammatory disease. A compromised ocular surface cannot protect itself from bacteria with full efficacy. Although NSC patients don't have full-blown bacterial infections, their eyes are susceptible to some bacterial disease components.

Patients of all types get NSC and may present with redness in the conjunctiva and lid edges, as well as some swelling, burning or foreign-body sensation. You may see some purulence in the ocular secretions, but far less than you see with bacterial conjunctivitis.

Evaluating the Patient

A 37-year-old man came to me with bilateral red eye, which he'd been experiencing for 4 days. He said he'd had this problem every few years in the past, but the redness, slight discharge and mild discomfort drove him to seek help this time. The patient had stopped wearing his contact lenses.

An exam showed no change in visual acuity. The patient had no pain, minimal photophobia and no preauricular adenopathy. However, he had mild blepharitis with minimal meibomian gland inclusions. The conjunctiva showed 1+ to 2+ injection with no follicles and trace papillae. The corneal exam was clean with no infiltrates. The cornea did not stain, but there was inferior conjunctival staining with lissamine green.

With any diagnosis of NSC, it's important to rule out other causes that require different drug treatments. With no history of allergy and no ocular itching, this case clearly wasn't allergy. Because of the patient's binocular presentation, the presence of lid disease, the recurrent nature of the problem and the absence of follicles or a history of fever or colds, I ruled out a viral cause. A bacterial cause was unlikely, because bacterial infection would be more aggressive and uncomfortable and would cause a more mucopurulent discharge.

It was clear to me that this patient almost certainly had both an inflammatory and an infectious process at work — weighted significantly toward the inflammatory component. I diagnosed him with inflammatory NSC.

The patient most likely had recurrent Staphylococcal blepharitis, and I reasoned that dead bacteria probably were falling from the lid to the ocular surface and causing an immunologic challenge. The meibomian gland dysfunction was the nutrient medium for the bacteria that caused the NSC. The bacteria, both alive and dead, were activating the body's immune defenses and causing hypersensitivity.

Winning the War

Unlike patients with allergic conjunctivitis who need a steroid alone, or patients who need a strong antibiotic for bacterial disease, this patient needed a combination treatment to battle inflammatory NSC. Although the primary problem was inflammatory, I wanted to cover all bases in case there was some infection.

I prescribed a dual-action corticosteroid and antibiotic, loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension (Zylet), four times a day for 7 days. The antibiotic would reduce the infectious component of the disease, while the corticosteroid would act to quiet the body's immune response. In cases like this, where inflammation exists on the external eye, the patient doesn't need a ketone steroid and the associated risks of cataract and glaucoma.

When the patient returned after 1 day, his symptoms were resolved. The conjunctival injection had improved dramatically, and he had resumed normal activities just 12 hours after starting the combination treatment. He finished his week on the prescription and didn't need additional treatment. To reduce bacteria on the lids, I ordered lid washes and warm compresses, and I started the patient on a flaxseed oil and fish oil supplement to improve meibomian gland secretions.

Case Study: Nonspecific Conjunctivitis
Sex: Male Age: 37
Signs and symptoms:
■ Bilateral redness
■ Slight discharge
■ Mild discomfort
■ Mild blepharitis with minimal meibomian gland inclusions
■ 1+ to 2+ conjunctival injection with no follicles and trace papillae
■ Recurrence of symptoms every few years
■ No history of allergies, colds or fever
■ Inflammatory nonspecific conjunctivitis
■ Loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension (Zylet) four times a day for 7 days
■ Permanent regimen of lid washes, warm compresses and a flaxseed oil and fish oil supplement
■ The patient resumed normal activities 12 hours after starting the combination drug. Conjunctival injection improved dramatically and symptoms resolved after 1 day. He used loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension for 1 week of treatment and required no further treatment.

Dr. Donnenfeld is medical director of TLC Laser Center in New York and a partner with Ophthalmic Consultants of Long Island and Connecticut.


Zylet is indicated for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists and where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain a diminution in edema and inflammation.

Important Safety Information

As with other steroid anti-infective ophthalmic combination drugs, Zylet is contraindicated in most viral diseases of the cornea and conjunctiva and also in mycobacterial infection of the eye and fungal diseases of ocular structures. Prolonged use of corticosteroids may result in glaucoma, as well as increase the hazard of secondary ocular infections. The incidence of adverse events reported by subjects treated with Zylet included injection (approximately 20%) and superficial punctate keratitis (approximately 15%). The development of secondary infection has occurred after use of combinations containing steroids and antimicrobials. NOT FOR INJECTION INTO THE EYE. Steroids should be used with caution in the presence of glaucoma. The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. If this product is used for 10 days or longer, intraocular pressure should be monitored even though it may be difficult in children and uncooperative patients.

Optometric Management, Issue: August 2007