Blepharitis OPT 539 Ocular Disease I PDF

Blepharitis OPT 539: Ocular Disease I Scott D. Klemens, O.D., F.A.A.O. September 3, 2024  Objective Introduce and review major types of anterior blepharitis Staphylococcal and Seborrheic Introduce and review angular blepharitis Introduce and revie...

Blepharitis OPT 539: Ocular Disease I Scott D. Klemens, O.D., F.A.A.O. September 3, 2024  Objective Introduce and review major types of anterior blepharitis Staphylococcal and Seborrheic Introduce and review angular blepharitis Introduce and review Demodex  Blepharitis Anterior Blepharitis: Inflammation centered around eyelashes and follicles Staphylococcal Seborrheic Mixed Posterior Blepharitis: Inflammation involving Meibomian glands and gland orifices Meibomian seborrheic Meibomian gland dysfunction (MGD) (aka: meibomianitis, meibomitis) Angular Blepharitis Staphylococcal Moraxella  Primary vs Secondary Primary Secondary More involved etiology and Result of specific disease entity complex presentation instead of the cause itself Rosacea Infectious processes Seborrhea Bacterial vs Viral Hypersensitivity caused by Infestations Staphylococcal toxins Phthiriasis or Demodex *Overlap of signs and symptoms  Acute vs Chronic Acute Chronic Causes Causes Infections, infestations, Trauma, Poor hygiene, seasonal/perennial Toxicity, acute allergies allergies, ocular rosacea, make-up overuse Signs/Symptoms Hyperemia, edema, telangiectasia, Signs/Symptoms flaking, debris, discharge, FB Lash involvement, ulceration, sensation, painful hordeolum, dry eye  Staphylococcal Blepharitis Etiology: Infection of the lash follicles and lid margins with Staph Staphylococcus epidermidis (S. epidermidis) More common: Is normally present on the lid margins (normal flora) of most patients Staphylococcus aureus (S. aureus) Less common: Is normally present of the lid margins of a small number of patients  Inflammatory Response Mechanism: Production of lipase by the bacteria Might alter tear lipid spectrum Cause the increase of Free Fatty Acids that are irritants to the eyelid May induce inflammation and hyperkeratinisation of Meibomian orfice Effect: Dilation of blood vessels (redness) Increased vascular permeability (edema + blood proteins) Movement of PMNs (Polymorphonuclear neutrophils) from blood into tissue If inflammatory response is cause by bacteria, lots of PMNs move from blood to tissue to fight the infection through phagocytosis Dead PMNs + Protein clot = Pus (***The presence of pus = bacterial infection***)  Symptoms Variable depending on severity and Variable depending on time of day damage to tissue Worse upon awakening FB (foreign body) sensation, grittiness Buildup of crusts during sleep Stinging, burning, irritation Exotoxin-caused SPK during sleep Pain Worse at the end of the day Tender lids Dry eye symptoms Possible Itching Clinical Signs  Crusts Crusts (flakes) Starts at base of lash Looks like “impaled cornflake” Strongly suggest staph exotoxin activity Keratinized plaque  Clinical Pearl Grading Scales Efron Grading Scale Should always grade your findings when applicable Allows you to determine if condition is improving or progressing Trace-4+ (Trace very early signs > 4+ most severe) Trace 4+  Lids Erythema Diffuse redness along lid margin Edema Puffy from fluid accumulation Tender to palpation ***Acute***  Lids cont. Lid neovascularization Glomerular fronds of vessels at margins Deeper vessels causing a pink “cast” Tylosis Thickening of the eyelid tissue Indurated Hardened ***Chronic***  Collarettes Cylindrical tubes of material that go up the eyelash base Sleeves = start at last base Collarettes = go higher up the eyelash base  Eyelashes Exotoxins can damage follicles and cause structural changes Madarosis = loss of lashes Poliosis = whitening of eye lashes Trichiasis = misdirected lashes Should consider epilation if touching cornea  Secondary Conditions Blepharoconjunctivitis Punctate Epithelial Erosion (PEE) Secondary conjunctival infection Pooling of exotoxins in tear lake Inferior 1/3 of cornea  Clinical Pearl PEE = epithelial cell loss in cornea Small divots in the cornea Will stain with fluorescein (enhanced viewing with cobalt (blue) filter) The pattern of the PEE can indicate possible etiology High association with ocular surface dryness Treatment  Lid Hygiene Warm Compresses Lid Scrubs Softens and loosens crusts Primary treatment for blepharitis Improves blood flow Scrub lid margins to remove debris 10-15mins/time bid to qid Bid to qid Lid wipes, foam cleansers Can manage most mild cases  Lid Scrubs Diluted baby shampoo, not recommended anymore Lid wipes Prepared lid cleaners, one-time use i.e. Ocusoft Foam Cleansers Scrub eyelids and wash with water, some are no rinse Recommend using washcloth, cotton ball, lid pad Hypochlorous Acid 0.02% Natural antimicrobial, gentle, non-toxic  Antibiotics Ointments preferred over drops in lid disease Moderate: qhs or bid Severe: tid or qid Remove crusts before applying *Should apply to finger or q-tip before applying to lids Avoid direct application from tube (contamination & quantity)  Ab cont. Bacitracin Cell wall inhibitor, excellent against staph, little hypersensitivity Polysporin (bacitracin + polymyxin B), Neosporin (bacitracin + polymyxin B + neomycin) Erythromycin Macrolide, good against staph, little toxicity Gentamicin Aminoglycoside, very good against staph Tobramycin Aminoglycoside, very good against staph ***Always prescribe at therapeutic dose and full course to combat resistance!***  Oral Ab Usually NOT the first choice of treatment Consider when unusually severe Patient unable to comply with ointment and lid hygiene Patient has considerable systemic illness Doxycycline: 100mg PO bid x 7-10 days Tetracyclines inhibit lipase synthesis by the bacteria Doycycline inhibits Staphylococcal exotoxin-induced cytokines and chemokines Are helpful even if the bacteria are resistant to the antibiotic effect  Steroids Consider in moderate to severe immune process Significant erythema, pain, tenderness Lid inflammation is very responsive to steroids Consider combination (Ab + Steroid) Tobradex (tobramycin + dexamethasone), Maxitrol (neomycin + polymyxin B + dexamethasone)  Clinical Pearl Considerations for prescribing steroids: Always need to monitor for secondary complications Increased IOP (steroid responders) Development of PSC (posterior subcapsular cataract) Usually takes 2-3wks, may not observe at 1wk follow-up ALWAYS MONITOR IOP!  BlephEx Before Medical grade disposable micro- sponge spins along edge of eyelids and lashes Removes scurf/debris and exfoliates eyelids Proparacaine usually instilled prior to treatment After Eyes rinsed afterwards 6 -8 minute procedure  F/U & Pt. ed. Follow-up 1-3 weeks depending on severity and medications prescribed Consider follow-up 2-3 weeks later If cornea is involved would see them within days Patient Education Lifetime condition with lifetime treatment and management Stress importance of routine lid hygiene! Return for flare-ups if medication needed  Associated Conditions Marginal Corneal Infiltrate Hypersensitivity to staphylococcal toxins Inflammatory response to toxins instead of direct infection White blood cells infiltrate cornea between epithelium and stroma (subepithelial) Ag (staph product) + C3a and C5a (chemotactic White spot in cornea of an Ab (produced in conj) factors for white cells from accumulation of white + the limbal blood vessels) cells Complement components (from limbal blood vessels)  Marginal Infiltrate White spot in peripheral cornea with clear area between limbus Does not stain with fluorescein DDx: PUK, Mooren’s Ulcer Tx: Treat bleph Add Steroid gtts q2h to qid (Prednisolone Acetate, Dexmethasone, Loteprednol) Combo (Tobradex, Zylet)  Associated Phlyctenule Type IV hypersensitivity reaction to staph toxins Elevated white lesion can be observed on conjunctiva, limbus, or cornea Can have associated vasculature *In past primary cause associated with tuberculosis (TB) Tx: Treat staph, steroids, combo  Seborrheic Blepharitis Seborrhea is a disorder of sebaceous gland function Unknown etiology, overproduction of secretion (excess oil production), disorder of retention of secretion Often associated with seborrheic dermatitis Chronic disorder of skin/head, dandruff is hallmark sign Also associated with Rosacea, acne juvenilis  Signs/Symptoms Greasy scales: foamy-looking, irregularly shaped, at bases of lashes or spiraling around lash Scurf: “dandruff-like scales” Symptoms often depend on other concurrent processes Scurf frequently asymptomatic Complaint of “mattering” in the am  Tx/Pt. ed. Lid Hygiene Lubricants Treat associated conditions Follow-up 2-4wks Educate patient on chronic nature and need for daily lid hygiene!  Considerations Primary Consideration: Rule-out staph involvement Can have mixed blepharitis with staph infection Treat the same as staph bleph Secondary Consideration: Rule-out dermatoses Examine other areas (facial blush areas, scalp, nose) Consider dermatology consult Tertiary Consideration: Rule-out meibomian gland dysfunction Can have meibomian seborrheic blepharitis (***Will cover next lecture***)  Angular Blepharitis Localized eczematoid inflammation at lateral canthi Two causative organisms Moraxella lacunata “epidemic” in institutional settings, geriatric population Staph aureus or epidermis (more common)  Signs/Symptoms Moraxella Wet Staph Dry and scaly Skin repeatedly drying out, scaling, cracking open Chronic lid irritation Possible Itching  Tx & Pt. Ed. Antibiotics needed for all cases of angular bleph Moraxella: Sulfacetamide, neomycin, erythromycin, polymyxin B Staph: Erythromycin and bacitracin Polysporin (bacitracin & polymyxin B): Good for both! Zinc sulfate 0.25%: Astringent action reduces maceration Vasoclear A, Clear Eyes ACR, Visine A.C. or in Zincfrin drops Culture and sensitivity if tx is ineffective Stress compliance to r/o tx efficacy  Demodex Mite infestation residing in follicles, primarily facial area Demodex folliculorum: hair and eyelash follicles Demodex brevis: sebaceous glands and Meibomian glands Observed in 100% of patients older than 70years 50% blepharitis likely associated with Demodex Feed on epithelial cells of the eyelid Females lay eggs in follicles, life span 14days  Signs/Symptoms Brittle, easily broken lashes, fall out spontaneously Pyramidal follicles from edema, mites, and eggs Collarette = highly diagnostic for demodex D. brevis can block Meibomian glands causing MGD Itching, burning, corneal irritation, and heavy eyelids Symptoms worse at night or dim lighting (mites recess into follicles with light) Irritation worse in warm weather  Demodex cont. Demodex can carry bacteria on its surface including Strep and Staph Cause increase in symptoms in rosacea patients Debris and waste may elicit host’s inflammatory responses via delayed hypersensitivity or an innate immune response  Diagnosis Clinical History High index of suspicion when blepharitis, conjunctivitis, keratitis, blepharoconjunctivitis in adult patients or recurrent chalazia in your patients are refractory to conventional treatments Associated madarosis or recurrent trichiasis Slit-lamp examination Collarettes and pyramidal elevation of eyelash follicles Microscopic confirmation Detection and counting of Demodex eggs, larvae, and adult mites in epilated eyelashes  Treatment Resistant to 75% alcohol, 10% povidone-iodine, and antimicrobials as erythromycin and metronidazole Tea Tree Oil (50%): highly effective against infestation Terpinen-4-ol (T4O) was isolated, more potent Cliradex, Ocusoft (Oust Demodex) Daily cleaning with wipe or foam cleanser Treat associated conditions  Xedmvy XDEMVY (lotilaner ophthalmic solution) 0.25% (Tarsus) Only FDA approved treatment for Demodex Sig: Instill 1gtt bid x 6wks Lipophilic agent, acts via mite GABA (gamma-aminobutyric acid) chloride channels Saturn-1/Saturn-2 Day 43 50% achieved reduction to no more than 2 collarettes vs 10%, 60% eradication vs 16%, 85% reduction collarettes to 10 or fewer vs 28%. $2k for 10ml bottle  Patient Education Stress Lid Hygiene! Assure patient that it is normal flora and common Takes 3-4wks for response Consider follow-up 4-6wks Questions?