A look at the diagnosis and treatment of anterior and posterior blepharitis.

For decades, the common belief was dry eye disease (DED) was primarily due to an inflammatory etiology that incited decreased aqueous production of tears. Recent research, however, shows that DED is a highly complex, multifactorial disease with malady of the lids as its leading cause.

Here, I discuss anterior and posterior blepharitis.

ANTERIOR BLEPHARITIS

The clinical signs of anterior blepharitis are biofilm on lids; conjunctival redness; conjunctival staining with lissamine green; increased ocular surface inflammation; inferior punctate corneal staining with NaFl; lid hyperemia; lid telangiectasia and saponification, or foaming of the tears, at the lid margin.

POSTERIOR BLEPHARITIS

Posterior blepharitis, or more commonly known as meibomian gland dysfunction, appears as decreased meibomian production and secretion; conjunctival and corneal staining; decreased TBUT; excessive tearing; hyperkeratinization of the meibomian ducts; meibomian gland atrophy and loss; meibomian gland obstruction and poor quality of meibum (a white “toothpaste like” solid substance).

Some dermatological diseases, such as seborrheic dermatitis, seborrhea and rosacea, also affect the meibomian glands, so careful attention to case history and the patient’s systemic disease(s) are critical to determining proper treatment. For example, many patients with ocular rosacea lack the typical facial skin characteristics in the early stages of anterior blepharitis and MGD, but the telangiectasia and erythema of the lid margins are usually present.

SHARED CHARACTERISTICS

Both anterior blepharitis and MGD can be inflammatory, non-inflammatory or even infectious. Additionally, the two classifications are not mutually exclusive and often occur simultaneously because of their proximal areas of involvement. The most common organisms isolated from patients who have chronic blepharitis include Staphylococcus aureus, Staph. epidermis, Corynebacteria and Propionibacterium acnes. Some of these organisms produce bacterial lipases that disrupt the normal tear layer and the meibomian gland secretions, causing ductal plugging, stagnation and pouting of the meibomian gland orifices.

The symptoms of both types of blepharitis are blurred or fluctuating vision; burning (usually a primary clinical symptom); discomfort; dryness; fatigue; foreign body sensation; grittiness; itching; photophobia; poor comfort with contact lenses and stinging.

TREATMENTS

Several treatment options are available for blepharitis and MGD, with many of them designed to treat both:

• Artificial tears. Used to lubricate the ocular surface and treat DED symptoms. (Both)
• Cosmetic treatments. Eye drops can “get the red out.” (Both)
• Intense Pulsed Light (IPL). This thermal heating of the glands increases gland secretions, destroying inflammatory feeder blood vessels on the lid margin, and decreases some of the lid margin’s bacterial load. (Both)
• Lid debridement. This removes the bacterial biofilm that contributes to inflammation and decreased meibomian gland function. (Both)
• Lid scrubs. These are used to achieve and maintain healthy lids and lashes in anterior blepharitis patients.
• Lid treatments. In-office devices use various forms of heat and massage on the lids to unclog the meibomian glands in MGD, increasing gland function and preventing glass atrophy and loss.
• Manual lid expression. This decreases MGD gland obstructions and improves gland secretions.
• Omega supplementation. This is taken to counteract the MGD inflammation that stems from dietary choices.
• Oral antibiotics. These provide an anti-inflammatory component to treatment. (Both)
• Prescription topical anti-inflammatory drops. Used to decrease inflammation. (Both)
• Short-term topical steroids. These are used to decrease inflammation. Topical combination antibiotics and steroids simultaneously deliver anti-inflammatory and infectious treatment. (Both)
• Warm compress. These work to decrease stagnation, increasing meibomian gland function and secretion in MGD patients.

MAKING A DIFFERENCE

We can offer many therapies to help improve symptoms of blepharitis and MGD and, therefore, quality of life. Treating these conditions allows us to practice medically, diversifying the scope of our care. OM

DR. JOHNSTON practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in co-managing cataract and refractive surgery patients. He is a consultant and speaker for Abbott, Alcon, Allergan, BioTissue and Shire. Email him at drj@gaeyepartners.com.