The eyelid margin can be affected by a number of different conditions. One such condition is blepharitis. Blepharitis has been classified broadly into anterior and posterior blepharitis. The anterior variant can be cured through medical treatment while the posterior variant often stays prolonged period of time and manifests as a chronic disease that cannot be cured.
A characteristic feature of blepharitis is inflammation of the eyelids though it is unclear what exactly causes it. It is possible that it is a result of an infection, either bacterial, parasitic or fungal. Despite advanced research and detailed literature being available, the exact cause has not been identified.
Staphylococcal infection of the lid margin is the commonest cause of anterior blepharitis. On examination, the eyelid margin will show golden crusting on the surface, culture of which will reveal antibiotic-resistant staphylococcus. Blepharitis caused by staphylococcal infections can be treated with a topical antibiotic.
Anterior blepharitis can also be caused by a mite called Demodex. Clinically, patients are affected by this will demonstrate cylindrical sleeves on the eyelashes. When these eyelashes are removed and examined in a microscope, the mites can be visible. The treatment for this condition is the application of tea tree oil.
In patients with a skin condition called rosacea, blepharitis may occur due to a combination of both bacterial infection and mites. The bacterium that is involved belongs to the class Bacillus which appears to have a symbiotic relationship with the mite. As a response to the mite infestation and the bacterial infection, an inflammatory response is generated which leads to the development of blepharitis. It is important to maintain good eyelid hygiene in order to prevent infection.
Anterior blepharitis may also occur due to excessive production of sebum. Seborrhoeic blepharitis typically presents as flicking in the eyebrow or in the lashes. Anti-seborrhoeic shampoos and the use of mechanical scrubs are recommended.
A rare variant of anterior blepharitis is called angular blepharitis. Here, there is temporary crusting of the angles of the eyelid that is associated with inflammation.
Posterior blepharitis is more common type of blepharitis. It is also known as meibomian gland disease. Typical treatment includes the use of simple measures such as moist warm compresses and massage to more elaborate therapies such as oral tetracycline or doxycycline medication. Nutritional supplements such as fish oils have been found to be useful. Advanced cases may require the use of topical erythromycin or steroids.
Treatment of blepharitis
Detailed treatment algorithms have been set forth by The Tear Film And Ocular Surface Society International Report On Meibomian Gland Dysfunction. In mild cases, simple hot soaks and scrubs are sufficient. Just a two-minute application of a warmth pack onto the eyelid surface can help loosen the crusts and any secretions making it easy for the scrubs to remove them completely. Over-the-counter eye cleansing pads such as the Ocusoft pads are useful.
In those who have mild to moderate disease, the use of AzaSite rubs into the lid margins seem to be beneficial. The solution is placed on an index finger which is then rubbed between the fingers and applied to both the lid margins at the point where the eyelashes join the skin. This is an off label use that seems to be beneficial.
Those individuals who cannot afford the use of AzaSite or in those who have arthritis and have difficulty performing fine movements and rubbing the solution directly onto the eyelids may have to use erythromycin ointment instead. The ointment is ideally applied just before going to bed as it can cause mild blurring of vision. In the event that the individual wakes up in the middle of the night, further application of erythromycin ointment is recommended.
In moderate to advanced disease, oral doxycycline in the dose of 50 mg per day (or twice daily) is required for a period of six months. Eyelid cleansing pads may be prescribed. Doxycycline use is associated with the side-effect of increased sensitivity to sunlight and hence it is of great importance that all individuals taking the medication wear sun protection gear when out in the open. Taking doxycycline in close proximity to the timing of a dairy rich meal can alter the absorption of the drug and must be avoided.
Blepharitis is closely linked to the development of dry eyes. For this very reason, the treatments given to treat blepharitis are often co-prescribed with artificial tears. There is some evidence that the use of omega-3 supplements can help reduce dry eye so often ophthalmologist will prescribe this is a part of the treatment in the early stages of the disease. The commonly used formulation is Tozal which is not only free from Mercury but also contains lutein and zeaxanthin, both of which can prevent age-related macular degeneration.
Those who have dry eyes of a moderate intensity along with blepharitis must use Fresh Kote, an artificial tears supplement. However, if the osmolarity of the tears is around 317 mOsm/L, it is recommended that Restasis be added to the prescription. This is often prescribed along with Lotemax gel given four times a day for two weeks and then reduced to twice a day for two weeks before stopping. The steroid in this compound helps reduce the pain that accompanies the use of Restasis and also provides great relief from symptoms.
Once the osmolarity of the tears crosses 325 mOsm/L per litre, then Fresh Kote use is abandoned and preservative-free artificial tears are used until the osmolarity drops.
Lipiflow and IPL
These are more advanced treatment options that are unfortunately time-consuming when it comes to managing blepharitis. They are reserved for patients who are struggling to manage their blepharitis despite taking all the above treatments mentioned earlier.
Lipiflow is a thermal lid massage procedure delivered in a pulsating manner over a period of 12 minutes. Some people have compared it to the spa treatments and patients have found great relief lasting up to a year.
When the procedure begins, eye cups are placed over the patient’s eyelids and the lids are gently warmed for the first two minutes. Following this, pulsations begin and the excessive secretions that are present in the eyelids are expelled into the eye cup. After 12 minutes, these eye cups are removed and thrown away (they are not reused). The maximum benefit from this treatment is experienced over a period of days to around six months. Following this, the benefit continues for up to 12 months occasionally extending up to 36 months.
The findings that confirm that Lipiflow works have been demonstrated in clinical trials as well. Effects last up to one year. In addition, the improvements noticed in the meibomian gland secretions at baseline were maintained at one year.
From experience, ophthalmologists have found that patients very rarely require repeat treatment within a year. Over a period of time, one item is removed from the treatment regime in a gradual fashion.
Intense pulsed light therapy has also been used to manage blepharitis. Here, a laser is directed towards the meibomian glands so as to completely close the blood vessels in the eyelid margin i.e. the telangiectasias.