blepharitis
BLEPHARITIS
Blepharitis is an inflammation process affecting the eyelid margins, eyelash follicles or openings of the anteriorly-placed accessory lacrimal glands and the posteriorly-placed Meibomian glands that causes ocular irritation and redness acutely but usually chronically.
It may have periods of exacerbations and remissions.
It usually occurs in middle-aged adults but can also start in childhood.
Can affect vision by disrupting the surface of the cornea and the bulbar conjunctiva; may influence tear film composition.

Principles of Therapy

  • Early detection & appropriate management can reduce signs & symptoms of blepharitis & prevent permanent structural damage & possible loss of visual function
  • Treatment options are often used in combination

Goals of Treatment

  • To alleviate signs & symptoms
  • To reduce risk of structural damage
  • To prevent permanent loss of vision

Pharmacotherapy

Topical Anti-infectives

  • Ointments (eg Bacitracin, Erythromycin, Neomycin, Tobramycin, Gentamicin)
    • Helps to reduce the bacterial load of the eyelashes & conjunctiva
    • Placed on the lid margin up to 4 times a day or once at bedtime
    • Should be applied in the lid margin to avoid ocular surface toxicity
    • Bacitracin & Erythromycin are effective agents for initial therapy
    • Neomycin, Tobramycin & Gentamicin have been recommended for chronic therapy
  • Ophthalmic solutions (eg Azithromycin)
    • Improves secretions of the meibomian gland & decreases redness in the eyelid
  • Frequency & duration of treatment is based on the severity of blepharitis & response to treatment

Systemic Anti-infectives

  • Tetracyclines (eg Doxycycline, Minocycline)
    • Decrease keratinization & lipase production in Staphylococcus epidermidis & Staphylococcus aureus
    • Used in patients w/ meibomian gland dysfunction (MGD) whose chronic symptoms are not adequately controlled w/ eyelid hygiene & in patients w/ ocular manifestations of rosacea
    • Given daily & tapered after clinical improvement is noticed usually 2-6 weeks
    • Can be given also in intermittent courses depending on the exacerbation of symptoms
  • Macrolides (eg Erythromycin, Azithromycin) have anti-inflammatory activity
    • Oral Azithromycin is an alternative to oral tetracyclines for blepharitis

Topical Corticosteroids

  • Brief course of corticosteroids can be used in patients w/ eyelid or ocular surface inflammation (eg severe conjunctival injection, marginal keratitis, or phlyctenules)
  • Tobramycin/Dexamethasone ophthalmic suspension & Azithromycin in a sustained release system showed reduction in the signs & symptoms of blepharitis
  • Corticosteroid eye drops or ointments are applied several times a day to the eyelids or ocular surface for no more than 2 weeks
  • Can be tapered & discontinued once the inflammation is controlled & used intermittently to maintain patient comfort
  • Use the lowest effective dose & avoid long-term use in order to minimize side effects [eg elevated intraocular pressure (IOP), cataract, & exacerbate the infectious process] that may lead to superinfection
    • Site-specific corticosteroids (eg Loteprednol etabonate) & corticosteroids w/ limited ocular preparation (eg Fluorometholone) can reduce the adverse effects

Topical Cyclosporine

  • May be helpful in posterior blepharitis & w/ coexisting dry eye syndrome

Ivermectin

  • Showed to be effective in some cases of recalcitrant Demodex blepharitis

Non-Pharmacological Therapy

Eyelid hygiene

  • Includes warm compresses, eyelid massage & scrubs
  • Can be done once or twice daily

Warm Compresses

  • Applying/placing warm cloth on closed eyelids for 5-10 minutes
  • Softens adherent encrustations, liquefies the solidified sebum in the meibomian ducts & dilate the ducts
  • Use hot tap water on a clean cloth or heated gel pack for sustained warmth
  • Helpful as initial treatment for posterior blepharitis

Eyelid massage

  • Brief, gentle massage of the eyelids done immediately after warm compresses
    • Meibomian secretions can be expressed by vertical eyelid massage
    • Removal of crusting from the eyelashes can be achieved by horizontally rubbing the eyelid margins
  • Ensure that the patient has the necessary skill to perform the above maneuvers safely
  • The washcloth used in the warm compresses or a clean fingertip may be used during the massage
  • Very useful as initial treatment for anterior blepharitis

Eyelid scrubs

  • Clean the eyelid by gently rubbing the base of the eyelashes & lid margin w/ diluted baby shampoo (1:10 in water) or eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip
  • Avoid vigorous rubbing/washing as it can further cause irritation
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