Lid inflammation: ignorance isn’t bliss

Your patients’ red irritated lids need your attention. Disregarding them will come back to haunt both of you.

By Robert Calandra, Contributing Editor and Christine Bahls

Eyelid inflammation consistently plays second fiddle to dry eye disease in the world of ophthalmology. And for understandable reasons: DED is a major danger to the ocular surface, and can affect vision permanently.

But the second fiddle can become the concertmaster; so diagnosing the inflammation correctly, and then treating it correctly, is worth all your time and effort.

Lid hygiene is part of the dry eye process,” says Patti Barkey, COE, of Bowden Eye & Associates in Jacksonville, Fla. “And lack of lid hygiene leads to blepharitis.” Ignoring blepharitis, she continues, leads often to meibomian gland disease — which then leads to ocular surface disease.

When healthy, meibomian glands express an olive oil-like solution that spreads when the person blinks. The solution goes into the tear layer and comforts the ocular surface.

There is good reason to discuss strategies with patients to reduce the bacterial and parasitic load of the eyelids, says Laura Periman, MD, a cornea and refractive trained ophthalmologist in Redmond, WA.

“Before we didn’t have great products. But now we do.”

To the rescue

Several lipid layer-focused products exist. Dr. Periman says she finds these products helpful in evaporative dry eye disease while working toward physiologic restoration of meibomian gland function. Tears Again Advanced Liposomal Spray (OcuSOFT); Retaine MGD (OcuSOFT); Refresh Advanced (Allergan); and Systane Balance (Alcon) help slow down evaporative losses.

A closer look

Avenova daily lid cleanser (NovaBay). “If a patient has moderate to severe [blepharitis] or I am about to operate on them and really want to decrease the risk of infection I go immediately to Avenova,” says Anne Rowland, MD, Eye Specialty Group, Memphis, Tenn. Ms. Barkey likes Avenova because it helps with compliance. Older products weren’t getting the job done, she says, but the stronger products that are now out like Avenova are doing the job. Dr. Periman says it is a natural, antibiotic-sparing approach to cleaning eyelids and reducing the bacterial load of the ocular surface prior to cataract surgery.

Cliradex (biotissue). This lash, eyelid and facial cleaner is made from the biologically active component of tea tree oil. Dr. Periman says it is “fantastic in cases of Demodex. If you observe cylinders around the eyelashes, or have a recalcitrant case of blepharitis, think Demodex mites.”

OcuSOFT lid scrub (OcuSOFT). Dr. Periman says she finds it effective with the right technique and compliance but avoids it in patients with a significant evaporative dry eye component or patients with an incomplete lid seal. “I don’t want to strip the oils further and worsen the evaporative load.”

BlephEx (RySurg). Dr. Rowland likes BlephEx.

This lid-scrubbing instrument is intended for patients with blepharitis; the instrument is a micro-sponge that exfoliates the eyelids, removing bacteria and debris from eyelashes. She compares the in-office process to using an electric toothbrush. “It’s a great technique for somebody who is not going to be compliant at home or has tremors or is too elderly to be able to do that kind of lid wipe at home.”

Dr. Periman likes it too. It deep-cleans, and is particularly effective for those with seborrheic and demodex disease. “BlephEx debulks the bacterial, parasitic and debris load.”

LipiFlow. Dr. Rowland says most patients see some relief after using this in-office treatment, even those who don’t find relief from other treatments. “Dry eye is so incredibly common, especially in women and the elderly and with all the medications people are taking for high blood pressure and cholesterol, all of which can worsen dry eye.”

Dr. Periman shares her enthusiasm. “LipiFlow gives patients more functional reserve in their day to day life. Treating MGD with this modality is an important component of physiologically restoring the entire Lacrimal Functional Unit. After the procedure, patients’ maintenance program can often be simplified.”

Gaining control

Dr. Periman says control of bacterial overgrowth likely happens quickly with Avenova and OcuSOFT or SteriLid (TheraTears).

Demodex control takes longer. The adults might die, but the eggs remain. It takes three to four months of focused clinical and home effort to eradicate them. Bed partners should be examined and treated. If pets share the patient’s bed, they be examined by a veterinarian and treated for Demodex if appropriate.

“With MGD, it’s a chronic battle requiring long-term focus and attention. Full medical management appropriate for the level of severity along with thermal pulsation and possibly IPL are excellent strategies to improve MGD over the long haul.” OM