Blepharitis: Blink and You'll Miss It

Clinicians sometimes overlook lid disease in their haste to diagnose dry eye, prolonging both.

BY THOMAS JOHN, M.D.

The ocular irritation brought on by dry eye can be a near-constant burden for patients, consistently interfering with activities of daily living and requiring frequent use of artificial tears throughout the day. Tear supplements are effective and popular, but provide only temporary relief. Greater vigilance to signs of blepharitis and more aggressive management of lid disease has the ability to not just alleviate dry eye symptoms but to foster recovery and remission in cases secondary to lid inflammation. However, the connection between blepharitis and dry eye is frequently overlooked, both in research circles and in clinical practice.

If blepharitis interferes with the ability of the Meibomian glands to secrete lipid to the ocular surface, tear film abnormalities will produce a chronic, low-grade dry eye syndrome. However, because the dry eye symptoms are more prominent in the patient's mind (its symptoms are likely what motivated the patient to seek care) the clinician may focus too much on efforts to increase tear quantity and alleviate discomfort, giving insufficient attention to the lid disease that ultimately is the culprit.

In my opinion, clinicians should not look at blepharitis as a distinct entity; instead, my approach is to consider ocular surface disease as being comprised of three elements: (1) blepharitis, (2) dry eye and (3) ocular allergy. These can exist independently or can overlap. Treating just one component may be insufficient as a long-term strategy. The actions we take — or fail to take — in managing blepharitis will have consequences for the patient's corneal health and overall ocular comfort. If the practitioner treats only the dry eye symptoms without adequate assessment of lid margin disease, both conditions will persist and patients will be quite frustrated and dissatisfied with the quality of care they received.

Clinical Clues

Blepharitis can present in a variety of ways, resulting from different but often interrelated mechanisms. Anterior blepharitis of the lid margin can be either infectious or noninfectious in nature, due to Staphylococcal infection in the former case or seborrheic dermatitis in the latter. A collarette or "sleeve" around the lashes indicates Staph. infection while scaly dandruff-like debris on the lid margin occurs in seborrheic blepharitis. It's important to note that both of these, however, can occur at the same time.

Involvement of the Meibomian glands is considered posterior blepharitis. This, too, can occur concurrently with anterior blepharitis, if the lid inflammation results from seborrhea, or as a consequence of it in infectious cases. Excess oil production in patients with overactive sebaceous glands provides a breeding ground that allows Staph. organisms in the normal ocular flora to multiply, resulting in infection of the Meibomian glands. This, in turn, promotes dry eye if Meibomian gland dysfunction inhibits lipid secretions to the ocular surface. Lipid secretions promote spreading of the tear film and prevent evaporation.

Blepharitis, dry eye and ocular allergy share many symptoms, such as itching, burning, erythema, excessive tearing and foreign body sensation. Prominent cases of blepharitis are likely to be identified by both patient and doctor, but less overt presentations may mistakenly be considered dry eye, given its more pronounced symptomotology.

Slit lamp findings tend to be more revealing than patient reports. Unfortunately, lid disease is highly underdiagnosed simply because clinicians don't spend enough time evaluating the lids. When a patient presents with complaints of sandy sensation, burning and stinging, the clinician will immediately suspect dry eye, and the first ocular structure evaluated tends to be the cornea. Finding evidence of superficial punctate keratitis (SPK), the ophthalmologist may be apt to confirm his suspicions and manage it with cyclosporine A and artificial tears, giving the eyelids and lid margins only a cursory evaluation, if any.

In my diagnostic approach, the corneal examination comes last rather than first. I consider the lid margin as a "landing strip" for an airplane, so to speak, and traverse that entire strip with the slit lamp before "landing" on the cornea. I break the slit lamp exam down into four steps:

1. The eyelids and lashes. Classic signs of blepharitis to look for include swelling or thickening of the lids, crusting around the lashes, adhesion of lashes, lid margin vascularity and blocked Meibomian glands. In posterior blepharitis, expression of the gland may reveal opaque, inspissated lipid secretions with the consistency of toothpaste, or no secretion at all in the event that the gland orifices are obstructed by scarring secondary to inflammation.

2. The tear meniscus. Next, consider the tear meniscus at the junction of the posterior lid margin and conjunctiva. Is the meniscus of normal quantity or abnormally decreased? These two steps alone are often sufficient to determine for the most part if the patient has dry eye — without yet looking at the cornea — and whether blepharitis is the culprit.

3. Tarsal and bulbar conjunctiva. Beginning with the inferior lid margin at the base of the tear meniscus, progress inferiorly along the tarsal conjunctiva to the fornix and then superiorly over the bulbar conjunctiva to the limbus. Mild hyperemia and injection of the bulbar conjunctiva are typical of blepharitis; prominent redness and chemosis may be more indicative of ocular allergy or bacterial infection.

4. Cornea. Now — with an appreciation for the potential contributing factors of the lids and conjunctiva — assess corneal integrity and tear film stability. Epithelial erosions and SPK are characteristic of dry eye, and rapid tear breakup time (typically defined as less than seven seconds) is especially indicative of blepharitis-induced tear film abnormality. Insufficient lipid secretions to the ocular surface cause tear instability and evaporation of aqueous tears, resulting in evaporative dry eye.

Other telling signs include the condition of the patient's hands and face. Rheumatoid arthritis is strongly associated with dry eye and should be suspected if swelling of the fingers and joint deformities are present. Facial signs of acne rosacea suggest a high chance of posterior blepharitis due to Meibomian gland disease. These insights can be gleaned from observation during the medical history before beginning the slit lamp evaluation.

Once blepharitis has been established and its potential impact on ocular surface disease assessed, the clinician must identify a likely cause and eradicate or control the disease state as best as possible. As discussed, preexisting conditions such as seborrheic dermatitis may be revealed during the exam. One potential etiology to consider in glaucoma patients is allergic reaction to the benzalkonium chloride (BAK) preservative found in some medications. Given the chronic nature of glaucoma therapy, a BAK-free alternative should be considered. If seborrhea or acne rosacea is the precipitating factor, a dermatology consult may be necessary.

Treatment Considerations

One reason that blepharitis has taken a back seat to dry eye is the relative lack of effective treatment options for it. With few management options to offer other than lid hygiene, clinicians tend to gravitate toward the area where they can have greater impact — namely, dry eye symptoms.

Teaching patients the importance of proper lid hygiene is of course a worthwhile option that can, in time, lead to resolution of symptoms for milder cases. Commercially-available lid scrubs or mild non-irritant baby shampoo diluted with water are effective, but require diligent compliance by patients. Patients requiring anti-inflammatory therapy for lid margin disease have historically been treated with a topical steroid eye drop or, if an infectious component is present, an antibiotic-steroid combination product. Topical cyclosporine A has been shown to be beneficial in both blepharitis and dry eye. Severe Meibomian gland infections may require systemic medications such as oral doxycycline or minocycline. In the future, androgen therapy may play a role in the treatment of ocular surface disease.

AzaSite (Inspire Pharmaceuticals, Durham, NC), a new medication that has both anti-inflammatory and anti-infective activity, can simplify the regimen for patients while also reducing side effects associated with steroid use, such as rise in IOP and cataract on long-term use. This topical azithromycin 1% solution makes use of a unique gel-like vehicle called DuraSite that extends the active ingredient's contact time with ocular tissues up to six hours, a distinct improvement over most other topical antibiotics. Patients apply one drop on a clean index finger or a clean applicator and apply it directly to the eyelashes on the lid margin. This administration method is unique in that the patient is applying the drug directly to the affected tissue rather than instilling a drop into the eye where it would become diluted by the tears. This is an off-label use of AzaSite.

A recent prospective open-label study I completed in the office setting¹ compared the efficacy of AzaSite with that of topical erythromycin ophthalmic ointment in treating chronic mixed (Staphylococcal and seborrheic) anterior blepharitis at 4- and 8-week durations of therapy. At week 4, 98.5% of subjects using AzaSite exhibited complete resolution vs. 37.5% for the erythromycin-treated group. At week 8, resolution remained 98.5% for the AzaSite-treated patients and was 50% for the erythromycin group. This was an independent study.

Another open-label study² looked at AzaSite's efficacy in 21 patients with posterior blepharitis. Ten patients used warm compresses plus AzaSite for 14 days; the other 11 received compresses alone. Significant improvement in Meibomian gland secretion and erythema was noted in those treated with azithromycin compared to the warm compress-only group. A third recent study³ excluded use of warm compresses from the regimen to gauge the effect of AzaSite in the absence of other modalities. This two-site pilot study of moderate to severe blepharitis with Meibomian gland involvement noted improvement in lid margin hyperemia and foreign body sensation after four weeks of AzaSite therapy.

Conclusion

The greater symptomotology of dry eye and the somewhat non-specific boundaries between the various forms of blepharitis may explain why eyelid disease is sometimes overlooked in favor of dry eye. Greater diligence toward eyelid evaluation can reveal the correlation between lid disease and dry eye, and newer medications are improving our ability to provide therapy targeted at its source. OM

References

1. John T, Shah AA. Use of azithromycin ophthalmic solution in the treatment of chronic mixed anterior blepharitis. Paper presented at: XXVI Congress of the European Society of Cataract and Refractive Surgery; 13-17 September 2008; Berlin, Germany. Annals of Ophthalmology (in press).
2. Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther. Sept. 9, 2008. E-pub ahead of print.
3. Inspire Pharmaceuticals, Inc. Data on file.

Thomas John, M.D., is clinical associate professor, Loyola University at Chicago; visiting professor, Department of Defense, Military Medical Academy, Belgrade, Serbia; and in private practice in Tinley Park and Oak Lawn, IL. He can be reached at (708) 429-2223 or tjcornea@gmail.com. Financial disclosure: Dr. John is a speaker and consultant for Inspire Pharmaceuticals.