treatment plan

Managing Blepharitis

BY WILLIAM L. MILLER, OD, PHD, FAAO

Blepharitis (Figure 1) is a commonly encountered but frequently unaddressed anterior segment disease. The term anterior blepharitis typically signifies staphylococcal disease affecting the anterior aspect of the lid margin while posterior blepharitis indicates meibomian gland involvement, either seborrheic, obstructive, or both. Posterior blepharitis is also referred to as meibomian gland dysfunction. Blepharitis in either form can cause dry eye symptoms as well as aesthetic issues due to the lid hyperemia and swollen lid appearance. It can also decrease comfort and wearing time in our contact lens patients.

Figure 1. Anterior and posterior blepharitis.

What to Look for

Diagnostically, anterior blepharitis exhibits scurf and collarettes at the base of the lashes as well as an oily appearance along the extent of the lashes themselves. For posterior blepharitis, observe the tarsal gland orifices for inspissations and express the glands to view their contents. Cheesy or more viscous secretions may indicate posterior blepharitis.

Posterior blepharitis can alter the lipid layer of the tear film and produce evaporative dry eye symptoms. Some practitioners also analyze the tarsal glands from the conjunctival aspect with a bright light source, typically a transilluminator aimed at the outer everted lid. Normal tarsal glands will have a piano key appearance versus altered and diseased glands that appear discontinuous and distorted.

Once thought to affect only elderly patients, blepharitis is now a very frequent complaint of younger patients. This disconnect may be because blepharitis is a chronic disease and our older patients have grown accustomed to or have accepted the symptoms over time, or perhaps an adaptation occurs with the elderly at the neurosensory level.

Management Options

Treatment strategies for anterior blepharitis have traditionally started with lid scrubs and hot compresses. However, many practitioners are opting for medical management much sooner than in the past. Standard ointment therapies before bedtime using either bacitracin or erythromycin along the lid margin will decrease the staphylococcal bacterial load. Others have treated anterior blepharitis with antibiotic/ steroid combinations such as Tobradex (Alcon) or an added steroid such as Lotemax (Bausch & Lomb) to an already prescribed regimen of bacitracin or erythromycin.

Another frequently prescribed anti-inflammatory is Restasis (Allergan), usually for patients who have dry eye dysfunction secondary to lid disease although there are some reports that Restasis may aid in posterior blepharitis cases. More recent studies have reported that Azasite (Inspire Pharmaceuticals) is effective in controlling anterior and posterior blepharitis (John and Shah, 2008; Luchs, 2008). A suggested application strategy is to have patients instill the drop, then close their eyes and smear the excess drop across their lid margin. Although reported in the literature, Azasite is not FDA approved for blepharitis conditions.

Lastly, oral medications can help control posterior blepharitis and stabilize the secretions for the tarsal glands. Examples include doxycycline or minocycline b.i.d., keeping in mind the usual warnings for children, pregnant women, and women taking birth control medications. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #165.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.