treatment plan

Marginal Blepharitis:
First of a three-part series on OSD

BY BRUCE E. ONOFREY, RPH, OD
JANUARY 1998

What does the popular television series "Star Trek" have in common with ocular surface disease (OSD)? The series is set in the 25th century where physicians can cure cancer, heart disease and almost any human malady --except for Captain Jean-Luc Picard's baldness! The same is true with OSD. Despite the capabilities of eye care today, the triad of marginal blepharitis, allergy and dry eye remains an incurable condition. As this three part series will illustrate, most doctors still treat this 20th century condition with 19th century techniques.

Symptoms

Patients with marginal blepharitis complain of chronic burning and scratchy, watery, sticky, matted shut eyes, as well as contact lens intolerance and complications. Of greater significance are the secondary tissue changes that occur, including inflammatory ocular changes associated with phlyc-tenular disease and episcleritis, and changes affecting the cornea such as chronic superficial punctate keratitis and increased risk of bacterial keratitis. Cataract or refractive surgery patients are at a markedly greater risk for infectious keratitis or endophthalmitis.

Understanding the Disease

Chronic marginal blepharitis is often thought to be caused by exotoxins released with chronic staphylococcus infection of the meibomian glands. It's true that coagulase negative Staphylococcus epidermidis, a common lid bacteria, infects the meibomian glands where secretions stimulate bacterial growth. However, free fatty acids, not staphylococcus exotoxins, are responsible for the secondary inflammation.

Management

The traditional approach to management -- hygiene and antibiotic therapy -- has exhibited variable success. Compliance is always a problem with a chronic condition, so a simple and effective approach has the greatest chance of success.

Step 1: Non-preserved artificial tears. Meibomian gland secretions, responsible for maintaining a healthy tear film, are abnormal in blepharitis patients. Stabilizing the tear film and providing sufficient tear volume to reduce the concentration of irritating staphyloccocus metabolic products is a cornerstone of therapy. Advise patients to use a preservative-free artificial tear or one of the new "soft-preserved" tears, like CIBA Vision's Genteal, on a regular basis.

Step 2: Lid Hygiene. Hot compresses applied twice daily followed by gentle lid scrubs can help to reduce meibomian stasis and debulk the bacteria. A variety of commercial lid scrub products are available. Incorporating the procedure with tooth brushing or bathing will probably improve compliance.

Step 3: Topical Therapy. Many practitioners apply antibacterial ointments to the lid margins. A better approach is to apply one or two antibiotic drops to the medial canthal area while the patient lies on his back with his eyes closed. Spread the drop across the lid margins and allow it to dry. A fluoroquinolone such as ciprofloxacin is a good choice because it's more effective against the antibiotic-resistant pathogens that cause marginal blepharitis.

Step 4: Tetracycline. Although effective in the short-term, topical steroids or antibiotic-steroid combinations like Tobradex (Alcon) don't address the cause -- free fatty acids. Tetracycline inhibits the ability of staphylococcus lipase to convert meibomian lipids to free fatty acids, thereby inhibiting inflammation. An adult dose of 50 to 100mg of doxycycline daily for one month followed by a reduced dose for another two months is usually effective. Avoid prescribing tetracycline to pregnant women and children.

Dr. Onofrey practices in Albuquerque