Blepharitis is an extremely common disorder that ophthalmologists diagnose and treat on a daily basis. Because the course of the disease and the response to treatment are so variable, this condition can be frustrating for both the patient and the doctor. Blepharitis patients can be some of the most challenging to manage, especially those with ocular rosacea, who tend to show little or no improvement with standard therapy.
Blepharitis is a major etiologic factor in evaporative dry eye and is more prevalent in older individuals. A study of patients presenting for cataract surgery found that the majority suffer from blepharitis, which can affect vision and comfort after surgery. Particularly with the improvements in intraocular lens (IOL) technology and surgical outcomes, the status of the ocular surface can be the limiting factor. As a result, there has been renewed interest in the treatment of blepharitis. In fact, the International Workshop on Meibomian Gland Dysfunction (MGD), which consisted of a panel of leading external disease specialists, convened last year and issued a report on MGD similar to the Report of the International Dry Eye WorkShop (DEWS) a number of years ago.
Blepharitis can be classified in a number of ways, but the easiest and most common method is to differentiate the type of blepharitis by location: anterior and posterior:
Anterior blepharitis affects the anterior lid margin, is characterized by lash debris (scurf and collarettes), and is associated with Staphylococcus and seborrheic dermatitis. Other signs of anterior blepharitis include madarosis (loss of eyelashes), pannus, phlyctenules, and corneal infiltrates. The mainstay of treatment is warm compresses and antibiotic ointment. Posterior blepharitis, also known as posterior lid margin disease or Meibomian gland dysfunction (MGD), involves the posterior lid margin and is characterized by an inflammation of the Meibomian glands. The common findings of MGD are telangiectasia, thickened secretions, and tear film debris. MGD is also associated with dry eye, chalazia, and acne rosacea. Treatment of MGD consists of warm compresses, massage, lid scrubs, antibiotics, and anti-inflammatory drugs. Specifically, the topical medications include antibiotic-steroid combinations, antibiotic ointments, AzaSite (azithromycin) (Merck), and Restasis® (cyclosporine ophthalmic) (Allergan). Oral therapies are tetracyclines and nutritional supplements (flaxseed and fish oils (i.e., omega-3 fatty acids). Treatment modalities are used alone or in combination in a stepwise fashion.
However, rarely do patients present with blepharitis that is purely anterior or posterior, but rather, they have a combination of disease, and there is usually some degree of dry eye as well. Therefore, there is quite a bit of overlap in treatment strategies for blepharitis.
New treatment approaches for MGD involve alternate methods of heating the lids (intense pulsed light [IPL] and LipiFlow Thermal Pulsation System [TearScience]) and an instrument to open the Meibomian gland ducts (Maskin™ probes from Rhein Medical).
Intense pulsed light is a common procedure performed by dermatologists and plastic surgeons to treat acne, rosacea, and other skin disorders. An intense pulse of bright white light (500–800 nm) is emitted by a flash lamp device. In 2003, Dr. Rolando Toyos first evaluated the role of IPL in treating patients with MGD and dry eye, and numerous centers across the United States now offer this technology. His treatment protocol consists of a double pass from ear to ear across the cheeks and nose, including the lower eyelids up to the lash line using the DermaMed Quadra Q4 Platinum IPL device. Patients receive one treatment per month for 4 months, followed by maintenance treatments 1–3 times per year. Pooled results show an overall success rate of 90% (improvement in patient-reported symptoms and physician-observed signs [i.e., increased tear breakup time and improved lid margin appearance]). I have personally performed this procedure and can attest to its efficacy (I do not have a financial interest in the technology or the device).
The LipiFlow device delivers heat to the inner eyelid surface and massages the outer lid surface during a 12-minute treatment, which melts and expresses the Meibomian gland secretions, respectively. The system obtained FDA clearance following positive results from a multicenter randomized controlled clinical trial; however, long-term data are not available.
Dr. Steven Maskin developed a miniature steel probe to open Meibomian glands obstructed by an intraductal fibrotic membrane. The 2-, 4-, or 6-mm probes are 76 microns in diameter, and the procedure is performed at the slit lamp under local anesthesia. Dr. Maskin and others have reported successful outcomes with this technique. Specifically, he has found that symptoms of lid tenderness are immediately improved in 75% of patients, and the duration of effect is usually 6 months or longer. Some doctors have expressed a concern that probing may cause trauma to the glands and more inflammation.
The renewed interest in blepharitis and novel approaches to treatment are a welcome development in ophthalmology. With a more complete understanding of the disease process, we now have better strategies for treating this common condition. Patients have already benefited from a variety of new procedures, and undoubtedly we will have more options to offer them in the future.