CLINICAL

  THE ANTERIOR

LASH OUT AT ANTERIOR BLEPHARITIS

HOW TO IDENTIFY AND CONQUER TWO COMMON FORMS

DURING THE process of converting paper charts to EHR last year, I revisited several old charts before they were scanned in to the electronic abyss. Not surprisingly, a lot of these patients were diagnosed with blepharitis. What was eye-opening (pun intended), however, is that I used to lump all these cases together, prescribing the same treatments with varying results. A lecture I attended on ocular surface disease five years ago prompted me to differentiate the many forms of blepharitis. This has resulted in effective treatment plans.

In the April issue of Optometric Management, I mentioned meibomian gland dysfunction, which is a form of posterior blepharitis and the leading cause of evaporative dry eye disease. This month, I discuss the etiology, symptoms, clinical signs, management options as well as the ICD-9 codes associated with the two common types of anterior blepharitis: staphylococcal blepharitis and seborrheic blepharitis.

ETIOLOGY

Staph. blepharitis can be caused by staphylococcal organisms that live on the eyelid, including staph. aureus and staph. epidermis. The risk factors for these organisms include warm climates and female gender. Normal flora and staph. bacteria are commonly seen on the skin and the eyelid, but at some point the staph. bacteria reaches a point at which it begins to cause eyelid inflammation, and symptoms arise.

Risk factors for seborrheic blepharitis include seborrheic dermatitis, acne rosacea, atopic dermatitis, psoriasis and dry eye disease. Seborrheic blepharitis is a dermatological condition, so another skin disease is usually involved.

SEBORRHEIC BLEPHARITIS SYMPTOMS

• Eyelid irritation

SEBORRHEIC BLEPHARITIS SIGNS

• Eyelash dandruff

• Mild redness of the lids

• Greasy flakes or scales around the base of the eyelashes

• Clustered meibomian glands that have an oily appearance near the lashes

• Excessive meibum secretions

SEBORRHEIC BLEPHARITIS MANAGEMENT OPTIONS

The treatments prescribed for this condition include the following:

• Lid scrubs. Prescribe anti-seborrheic shampoo and water on a wet towel, or lid cleansers, which have stronger antimicrobial properties and are less irritating to the skin than anti-seborrheic shampoos, initially b.i.d. for two weeks, then decrease to q.d. for maintenance therapy and PRN if it resolves.

• Steroid ointments used for two to three weeks. Prescribe b.i.d. for seven to 10 days in severe cases or when lid hygiene alone doesn’t work. Then, decrease to q.d. for two weeks, and stop if improvements are noted.

• Consultation with a dermatologist. Seborrheic blepharitis is also viewed as a dermatological condition and, oftentimes, patients can present with concomitant eczema, atopic dermatitis and scaling of the brow between the lids and seborrheic dermatitis of the face and scalp. Therefore, long-term care may include consultation with a dermatologist.

STAPH. BLEPHARITIS SYMPTOMS

• Eyelid irritation

STAPH. BLEPHARITIS SIGNS

• Red eyelids

• Scurf

• Erythema

• Lash loss

• Crusting and matting with lid debris

STAPH. BLEPHARITIS MANAGEMENT OPTIONS

The treatments prescribed for this condition:

• Lid scrubs. Prescribe diluted baby shampoo with water on a wet towel or commercial lid cleansers, such as foam cleansers, that contain hypochlorous acid (which disinfects), b.i.d. for two weeks, then q.d. as symptoms improve. (My practice retails lid hygiene products in office. I’ve found that physician-recommended products sold at the time of the exam increase patient compliance, decrease patient confusion with the overwhelming OTC choices available and capture extra revenue, which can add up because this disease is so commonly seen.)

Lid erythema, telangiectasia, loss of lashes and lid and conjunctiva inflammation in this staph. blepharitis patient.

• Warm compresses. Prescribe b.i.d. for one week and then q.d. until the condition improves. For maintenance, have the patient use warm compresses every other day. These offer symptomatic and therapeutic relief because most patients who have staph. blepharitis have meibomian gland dysfunction as well. (We also retail eye masks in our office for the same reasons as listed above.)

• Topical antibiotic/steroid combinations. Prescribe b.i.d. for seven to 10 days, then decrease to q.d. for one week and continue decreasing as signs and symptoms improve for patients who have severe or chronic staph. blepharitis. These drugs should be used in addition to the lid scrubs to increase the treatment’s efficacy.

• Oral medications. Prescribe these with combination drops/ointments when the combination drugs are insufficient. You can prescribe 50mg of doxycycline b.i.d. for two months, or a five-day course of oral azithromycin 500mg on day 1 and then 250mg/day.

NARROW YOUR APPROACH

To achieve the best outcomes in treating blepharitis, don’t approach each case the same way. Instead, identify the exact type of blepharitis, so you can develop a specific treatment regimen. Doing so results in positive outcomes. OM

JOSH JOHNSTON, O.D., F.A.A.O. practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in comanaging cataract and refractive surgery patients. Email him at drj@gaeyepartners.com, or visit tinyurl.com/OMcomment to comment.