Article Date: 8/1/2007

A Primer on Blepharitis
lid disease

A Primer on Blepharitis

ANDREW S. MORGENSTERN, O.D., Rockville, Md., & IAN D. RADEN, O.D., San Antonio, Texas

You must reinforce your knowledge of the signs and symptoms, risk factors and treatment of blepharitis for two reasons:

1. It can lead to several significant ocular complications (see "Complications of Blepharitis," page 44).

2. You can educate general practitioners who eventually refer cases to you that this is a chronic condition that can result in sight-threatening corneal changes if left unmanaged.

Complaints and culprits

Patients who have blepharitis present with redness and inflammation of the anterior and/or posterior lid(s). They also have a crust-like substance or flaky debris at the base of their eyelashes.

Symptoms include stinging, itching, foreign-body sensation or burning, excessive tearing, dry eye, photophobia and blurred vision.

Anterior blepharitis is most commonly caused by scalp dandruff (seborrheic dermatitis) and a build-up of bacteria (Staphylococcus). Both become fixed in and around the base of the eyelashes.

Dandruff is a normal function of the scalp, but when the skin turnover becomes more frequent, noticeable buildup occurs. The two different causes of scalp dandruff are internal and external. Some of the internal causes: hormonal imbalance, poor hygiene, poor health, allergies, stress, lack of sleep, type (heavy in sugars) of diet, poor diet, lifestyle, hygiene and genetics.

Knowledge of this lid disease will enable you to educate your patients and their primary-care physicians on its potential to cause serious ocular problems.

Some of the external causes are cold weather, dry, indoor heating, cosmetic sprays, gels, make-up and failure to clean lids and lashes.

Bacteria is part of the normal flora of our lids and lashes. When there is an overproduction of bacteria or a lack of hygiene, the bacteria can overwhelm the tissue. An over-abundance of bacteria eventually leads to blepharitis and in some cases infection of the affected tissue.

Meibomian gland dysfunction (MGD), which is the inflammation and clogging of the glands, causes the posterior form of blepharitis. As the meibomian glands produce oil, these oils must be released into the tears to create a healthy tear layer. If the glands become congested, they can produce sebum that sometimes appears as a "frothy" tear lake.

The sebum is produced when the gland cannot work efficiently to secrete oils. As the sebum dries up, it may attach to the lid or lash to become apparent as blepharitis.

Without proper hygiene, the consequences affect the palpebral and or bulbar conjunctiva, producing a process known as blepharo-conjunctivitis. If the cornea is involved, the condition may be described as blepharo-keratoconjunctivitis.

Patients at risk

Blepharitis has three risk factors:

acne. Scalp dandruff (seborrhoeic dermatitis), acne vulgaris (pimples) and acne rosacea have been implicated as causes for posterior blepharitis. These conditions predispose patients to blepharitis mainly by creating an environment on the skin that congests all the oil-producing glands necessary for a healthy dermis and epidermis.

poor lid hygiene and certain foods. Blepharitis is an end point of a continuum that may begin with poor lid hygiene. Since our lids are used to protecting and clearing our ocular surface, failure to remove all the offending agents collected throughout the day, results in these agents working against a healthy lid and ocular surface. Certain foods that contain sugar and/or artificial sweeteners, such as cereal, catsup and salad dressing, can exacerbate issues that affect the skin. Spicy foods have also been implicated.

compromised immune system. An intact and healthy immune system can help protect the lids and lashes from overproduction of the bacteria that causes blepharitis.

Much of the elderly population has all three of the aforementioned risk factors, so it should come as no surprise that blepharitis is most prevalent in this group.

Many elderly individuals have physical limitations that prevent them from practicing proper hygiene. In addition, it's widely known that as the body ages, the immune system weakens.1 And, acne rosacea, among other skin conditions, is common in the elderly.2

Consider: All healthy individuals have a certain amount of Demodex folliculorum and Demodex brevis (hair follicle mites). An over accumulation of these mites, however, has been linked with the pathogenesis of blepharitis.3 Studies have revealed that Demodex mites may play a role in acne vulgaris, acne rosacea, perioral dermatitis, seborrhoeic dermatitis and S. aureus — all causes of blepharitis.4-7

In one study of 435 patients ages three to 96, Demodex mites were found in 87% of those age 51 to 70 years and in 95% of those age 71 to 96. Further, 58% of all those infected with the mites suffered from chronic blepharitis.3

Complications of Blepharitis
■ Corneal infections and infiltrates (especially when combined with contact lens usage)
■ Dry eye and dysfunctional tear syndrome
■ Fungal keratitis
■ Angular keratitis
■ Dacryocystitis and dacryoadenitis
■ Acanthamoeba infection in cases with penetrating injuries or surgery (potentially blinding)
■ Chalazion Hordeolum
■ Blepharospasm
■ Entropion/Ectropion
■ Ptosis

Diagnosis

To diagnose blepharitis, use your slit lamp to examine both the anterior and posterior lid segments. It's important to note that a patient can have a combination of both anterior and posterior blepharitis. Evaluate both structures to rule-out the presence or absence of anterior and posterior components, as involvement of different tissues will dictate a differing treatment strategy.

Stretch and invert the lids to expose the entire area, so you can uncover any coexisting hidden ocular disease. In patients who have a ptosis or lid droop, for instance, the redundant skin tissue within the lid may hide underlying problems, such as acne or seborrhoeic dermatitis.

Anatomically, the bulbar conjunctiva migrates in to the palpebral conjunctiva, which lies adjacent to the lid margin. It's very easy to look at every feature of the eye as a separate entity, but in this case it may be important to imagine the lids and corresponding components as one unit.

Make sure to note specifically what part of the adnexa is involved to treat most effectively. Make careful notes in your chart as to the extent of lash vs. lid margin involvement. When the lashes are primarily involved, topical antibiotic ointments along with lid hygiene are the proper remedy. When the eyelids and glands themselves are involved, oral preparations may be required.

"Blepharitis" is a generic term. An example of a more descriptive and complete diagnosis is "posterior blepharitis with a secondary hyperemic lid margin."

Education

Prior to prescribing a treatment, educate the patient on his condition and the necessity for aggressive, long-term treatment.

In our practice, we explain the potential causes of the patient's lid disease and the fact that blepharitis can be a chronic condition that can recur if the root cause isn't properly eliminated. We then discuss the treatment plan, and we explain the need to return for follow-up, so we can gauge the effectiveness of the treatment and alter if necessary.

Treatment

Depending upon the root cause, some forms of blepharitis have the potential to be chronic and recurring.

Advise patients that controlling the condition is based upon the elimination of aggravating and mitigating factors. Medicinal therapies concentrate on eradicating organisms or improving physiology at six anatomical sites: the lids, lashes, lacrimal gland, conjunctiva (palpebral and bulbar), eyebrows and tear film.

Once you identify the root cause of the blepharitis, concentrate on that entity, but don't forget about the rest of the eye.

Employ lid scrubs. Instruct the patient to soak a clean washcloth in warm water and then place it on his eyes for five to 10 minutes, b.i.d. (upon waking and before bedtime) to help facilitate the expression of the meibomian glands. Then, tell the patient to massage his lids in a vertical motion (top to bottom on the upper lids and bottom to top on the lower lids) for about a minute to effectively express any debris in the lids' glands and to free the lashes of flakes and crust.

Prior to prescribing a treatment, educate the patient on his condition and the necessity for aggressive long-term treatment.

Finally, instruct the patient to use a separate, clean washcloth to wipe clean the eyelids. You may also recommend the patient take a nice hot shower prior to starting this, as doing so will open the glands and skin pores.

Use baby shampoo. If using the warm washcloth alone is not effective, have the patient apply baby shampoo on his lids and eyebrows, b.i.d. approximately 12 hours apart, as this will help to effectively eradicate some of the bacteria or debris. You can have the patient use the shampoo either straight out of the bottle, or he can dilute it with water. Regardless, have him scrub for 30 to 60 seconds.

Prescribe an over-the-counter (OTC) lid scrub. If the baby shampoo is not effective on the lids, prescribe an OTC lid scrub. Pharmacy shelves contain several products that have anti-microbial components to create a bacteriocidal environment while cleaning the lids.

Prescribe erythromycin ointment at bedtime. If the OTC lid scrub isn't effective, you may be dealing with a stubborn bacterial infection.

Erythromycin ointment applied before bedtime can eradicate this infection. Have the patient wash his hands prior to instillation. Then, tell him to apply a 1/4- to 1/2-inch thick ribbon of the ointment in the lower cul-de-sac of the lid with his finger. Tell the patient to never put the tube end up to the eye during application, as he could contaminate the ointment tube's tip.

Prescribe a topical steroid. Since inflammation is a tell-tale sign of blepharitis, treating it is necessary to resolve this part of the patient's problem. Prescribe a steroid, such as loteprednol or fluoromethalone (FML) q.i.d. Begin the steroid taper one week after the signs of inflammation have resolved or if you detect an intraocular pressure (IOP) spike. Check IOP at every visit.

Prescribe topical cyclosporine. If steroids alone aren't effective, use cyclosporine ophthalmic emulsion (Restasis, Allergan) b.i.d. approximately 12 hours apart. This off-label use of the drug successfully controls inflammation of the eyelid margin, which promotes healthier tear layers. In addition, it does not pose the risk of an IOP spike.

We use cyclosporine in conjunction with a steroid q.i.d. the first month or until the cyclosporine reaches its maximum effectiveness to add to the initial anti-inflammatory properties. I also prescribe a preservative-free lubricating eye drop every two hours to help dilute the tear film and help rid the eye of the offending agent that's causing the patient's blepharitis. Preservative-free solutions contain fewer additives, preventing further irritation.

Consider oral medication. Blepharitis patients with acne rosacea, fair skin and light eyes and hair are commonly at risk for MGD and over production of oil from the meibomian glands. Doxycycline 50mg b.i.d. or tetracycline 250 q.i.d. orally (NOTE: tetracycline cannot be used for pediatric patients) can also control MGD in posterior blepharitis cases and control oil production in the tear film.

Nutraceutical therapy. An Omega-3 fatty acid or supplements have been shown to help produce meibomian oils that aid in the decrease of the onset and production of blepharitis.

Remember: Stay knowledgeable of blepharitis, so you can help patients regain their comfort and preclude more serious ocular complications. It's also important so you can educate those primary-care practitioners who may minimize the seriousness of the condition. OM

1. Hodkinson CF, Kelly M, Alexander HD, et al. Effect of zinc supplementation on the immune status of healthy older individuals aged 55-70 years: The ZENITH Study. J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):598-608.

2. WebMD. Skin Problems & Treatments Guide. Skin Conditions: Elderly Skin Conditions. www.webmd.com/skin-problems-and-treatments/guide/elderly-skin-conditions. (Accessed July 10, 2007).

3. Czepita D, Kuzna-Grygiel W, Kosik-Bogacka D. Investigations on the occurrence as well as the role of demodex folliculorum and demodex brevis in the pathogensis of blepharitis. Klin Oczna. 2005;107(1-3):80-2.

4. Okyay P, Ertabaklar H, Savk E and Erfug S. Prevalence of Demodex folliculorum in young adults: relation with sociodemographic/hygienic factors and acne vulgaris. J Eur Acad Dermatol Venereol. 2006 Apr;20(4):474-6.

5. Moravvej H, Dehghan-Mangabadi M, Abbasiab MR, et al. Association of rosacea with demodicosis. Arch Iran Med. 2007 Apr;10(2):199-303.

6. Raszeja-Kotelba B, Jenerowicz D, Izdebska JN, et al. Some aspects of the skin infestation by Demodex folliculorum. Wiad Parazytol. 2004;50(1):41-54.

7. Clifford CW, Fulk GW. Association of diabetes, lash loss, and Staphylococcus aureus with infestation of eyelids by demodex folliculorun. J Med Entomol. 1990 Jul;27 (4):467-70.

Dr. Morgenstern is clinical director of TLC Laser Eye Centers in Rockville, Md. and teaches clinical refractive didactics at the University level.
Dr. Raden completed a residency in ocular disease and hospital-based optometry at the Baltimore VA Medical Center. He's the externship coordinator at the South Texas Veterans Healthcare System.


Optometric Management, Issue: August 2007