Download Anterior and Posterior Blepharitis

COVER STORY
Anterior and
Posterior Blepharitis
An overview of the options for treatment.
BY KATHERINE M. MASTROTA, MS, OD
T
he 2009 Executive Summary of the ICare in
America Survey (www.icareinamerica.com) suggested that as many as 28 million US adults are
affected by symptoms associated with blepharitis. Cognizant of blepharitis and its forms, eye care specialists are looking for options to manage the condition
successfully.
BACKGROUND
Blepharitis is generally categorized as either meibomian
gland dysfunction (MGD)/posterior blepharitis (Figure 1)
or anterior blepharitis (Figure 2), although these forms
rarely present independently. Generally, posterior and
anterior blepharitis are comorbidities that interact to
perpetuate the overall disease state of the eyelid.
Anterior blepharitis, including angular blepharitis, can
result from an overpopulation of bacterial lid commensals or Demodex (a ubiquitous mite) and from seborrheic changes of the lid margin. By causing inflammation,
irritation, and/or hyperkeratinization of the lid margin,
bacterial exotoxins and Demodex contribute to obstruction of the meibomian gland orifices. Chronic inflammation from meibum stasis and keratinization of the
meibomian gland’s ducts and orifices ultimately leads to
obstructive MGD, a loss of gland clusters, and atrophic
nonfunctional glands. In nonobstructive MGD, sometimes referred to as seborrheic MGD, copious amounts
of abnormal meibum are delivered to the tear film.
Additionally, bacterial lipases, acting upon meibum, create irritating free fatty acids that are released into the
tear film. MGD can occur as a primary disorder or secondary to acne rosacea.
Figure 1. Filigree-like vessels cross the lid margin in MGD.
Note the trapped lipid and irregular placement of the meibomian gland’s orifices as well as the early rounding of the edge
of the inner lid margin.
Figure 2. Debris and remnants of makeup harbor lipase and
exotoxin-secreting bacteria in an eye with anterior blepharitis.
34 ADVANCED OCULAR CARE MAY/JUNE 2010
COVER STORY
STRATEGIES FOR TREATMENT
Goal
The aim of treatment is to address infection, infestation,
and inflammation of the lid and lid margin as well as meibomian gland function and/or congestion. Therapy is prescribed to manage acute or chronic blepharitis. Lid disease
is dynamic in nature and affected by myriad factors, including the patient’s age, environment, medications, and
overall health. Because treatment must be flexible, therapies may be used in combination or interchangeably.
Lid Hygiene
Often, treatment begins with gentle cleansing of the
eyelid margin along the base of the eyelashes. Warm compresses and mechanical massage of the tarsal plate area
can be added in cases of posterior blepharitis. A warm
compress softens the wax in the meibum and loosens any
debris on the eyelid margin and eyelashes. Patients may
use a variety of homemade compresses (eg, a microwaveheated sock full of uncooked rice, a hardboiled egg
wrapped in a washcloth) or commercially available eyelidwarming devices (eg, gel packs, goggles).
Using the index finger to gently massage the closed
upper and lower lids expresses the meibomian gland’s
ducts and dampens the gland’s inflammatory response,
while increasing tear breakup time. The MG Expressor Kit
(Gulden Ophthalmics, Elkins Park, PA) is available for inoffice meibomian gland expression. Maskin Meibomian
Gland Intraductal Probes (Rhein Medical Inc., Tampa, FL)
were designed to probe the meibomian glands, thus
releasing presumed adhesions within the gland’s central
duct and allowing recanalization to enhance lipid flow.
Gentle cleansing of the eyelashes reduces bacterial colonization of the lids, washes away irritating bacterial toxins,
improves the health of the eyelash follicle, and stimulates
the egress of meibum. Because commercially prepared
cleaning products are free of unnecessary fragrances and
colorings, they avoid allergic reactions in sensitive individuals. Currently available by prescription are combination
kits that include doxycycline (to be discussed further), lidcleansing foams or solutions, and lid-warming devices.
Lid-cleansing preparations such as Ocusoft Lid Scrub
(Cynacon/Ocusoft, Inc., Richmond, TX) and tea tree oilbased Cliradex (Ocular Surface Research & Education
Foundation, Miami, FL) have both antimicrobial and acaricidal activity.1,2 Sterilid (Advance Vision Research,
Woburn, MA) is another popular choice for lid hygiene.
Seborrheic disease is thought to be due to a combination of an overproduction of skin oil and irritation from
the yeast Malassezia. The condition may respond to gentle overall cleaning with an over-the-counter dandruff
shampoo. It is important to caution patients against
overzealous scrubbing, which can exacerbate inflammation, create microabrasions in the dermis, and strip the
skin of its natural protective oils (sebum), making it susceptible to bacterial infiltration.
Over-the-Counter Tears
Various studies have demonstrated the correlation
between MGD and evaporative dry eye.3-5 Hydrating the
INTRADUCTAL MEIBOMIAN GLAND PROBING AND PHARMACEUTICAL INJECTION
BY STEVEN L. MASKIN, MD
Despite the availability of a wide array of topical and systemic therapies targeting the meibomian glands, meibomian gland dysfunction (MGD) remains an enigma. I concluded that understanding this disease and developing optimal
therapy require entering the gland itself. To achieve this
goal, I have developed in collaboration with Rhein Medical
Inc. (Tampa, FL) a system of sterile, stainless steel intraductal
probes of various lengths that have a diameter of 76 µm.
These instruments directly establish and confirm a patent
duct system. The probing system also has intraductal tubes
with an outer diameter of 104 µm to permit the injection
of a pharmaceutical agent after probing.
With a topical anesthetic ointment, patients tolerate the
procedure well. My coinvestigators and I reported the successful treatment and long-term relief of the symptoms of
refractory MGD with this therapy.1,2 Other surgeons have
had similar success.
Our studies have uncovered two distinct patterns of symptoms in obstructive MGD, both of which respond to probing
but at different rates, with up to 9 months of follow-up. Based
on our findings with the probes, we have identified four characteristics that may be used as a grading scale for the meibomian gland’s obstruction. It is also noteworthy that, after probing, patients have reported an improvement in symptoms
they had not previously recognized, a finding that supports
the notion that MGD exists subclinically. An article on these
findings has been accepted for publication in Cornea.
Steven L. Maskin, MD, is the founder of Focus on Females
Education Foundation, and he is in private practice at the
Dry Eye and Cornea Treatment Center in Tampa, Florida. A
patent on the described system of probes is pending.
Dr. Maskin may be reached at (813) 875-0000.
1. Maskin SL.Intraductal meibomian gland probing relieves symptoms of obstructive MGD. Invest
Ophthalmol Vis Sci.2009;50:e-abstract 4636.
2. Maskin SL,Warsinski C.Long term safety and retreatment data after intraductal meibomian gland probing
for obstructive meibomian gland dysfunction.Invest Ophthalmol Vis Sci.2010;51:e-abstract 6283.
MAY/JUNE 2010 ADVANCED OCULAR CARE 35
COVER STORY
ocular surface in aqueous-deficient dry eye disease via
supplemental tears tempers the inflammatory mediators
that can affect the function of the meibomian gland.
Additionally, lipid-containing tear supplements such as
Soothe XP with the lipid-restorative Restoryl (Bausch +
Lomb, Rochester, NY) bolster the oil-deficient tear film,
especially in advanced cases of meibomian gland atrophy.
Oral Tetracycline
Effective for patients who have ocular or dermatologic
rosacea, the oral administration of tetracycline has nonspecific anti-inflammatory properties that inhibit keratinization and suppress bacterial lipases.16,17 Current prescribing patterns favor low doses of doxycycline, the efficacy of which has been demonstrated.18
Omega-3 Fatty Acids
Supplementation with omega-3 fatty acids (coldpressed, pharmaceutical grade) encourages the production of anti-inflammatory prostaglandins and modifies the
composition of meibomian lipids.6,7 A variety of products
are available that contain combinations of fish, flaxseed,
and evening primrose oils. Although no consensus exists
regarding dosage, most clinicians suggest 2 g/day. Another
option is the off-label use of omega-3-acid ethyl esters
(Lovaza; GlaxoSmithKline) at a dose of 4 g/day.
CONCLUSION
It is important for both the clinician and the patient to
understand the complex and dynamic nature of lid disease. Treatment must be tailored to and modified as
demanded by the clinical presentation and the affected
individual’s symptoms.
Fortunately, the future holds promise for the treatment of blepharitis. Under development are devices to
aid in the evacuation of congested meibomian glands,
and researchers are studying the role of topically applied
hormones in MGD. ■
Topical Steroids and Antibiotics
Short-term therapy with ester-based steroids may
effectively break the inflammatory cycle in patients who
have significant lid disease or blepharoconjunctivitis.
These ester-based steroid-containing agents (Lotemax,
Alrex, Zylet; all from Bausch + Lomb) have a significantly
lower propensity to raise IOP or cause cataract formation
than ketone-based steroid preparations.8,9 Similarly,
monotherapy or combination therapy in the form of a
solution or ointment can be a useful means of directly
applying therapy to the eyelid’s margins or base.
Recent research showed that high concentrations of
topically administered azithromycin are achieved within
the ocular tissues.10 Additionally, macrolides have known
anti-inflammatory characteristics.11 The off-label use of
azithromycin (Azasite; Inspire Pharmaceuticals, Inc.) has
shown promise for the management of both the anterior and posterior forms of blepharitis.12-14 The topical
administration of azithromycin was found to effectively
reduce inflammation and modify lipid production, and
it may be effective at modifying the course of MGD.12 As
this is an off-label use, dosing regimes have not been
established. Anecdotal evidence suggests the safe and
effective management of blepharitis with courses of
Azasite for 1 month or longer.
Cyclosporine
The off-label use of cyclosporine (Restasis; Allergan,
Inc.) has proven useful for decreasing the number of
meibomian gland inclusions in eyes with MGD.15 More
important, however, is the improvement in aqueousdeficient dry eye, which can affect or exacerbate MGD
and vice versa.
36 ADVANCED OCULAR CARE MAY/JUNE 2010
Katherine M. Mastrota, MS, OD, is the center
director of Omni Eye Surgery in New York.
Dr. Mastrota is a consultant to and/or on the
speakers’ board of Allergan, Inc.; Bausch +
Lomb; Inspire Pharmaceuticals, Inc.; and Ista
Pharmaceuticals, Inc. She is on the scientific advisory
boards of Cynacon/Ocusoft and Noble Vision Group, LLC.
Dr. Mastrota may be reached at (212) 353-0030;
[email protected].
1. Yee R.Efficacy of Ocusoft Lid Scrub Plus on eradication of ocular Demodex.2008.Study on file with
Cynacon/Ocusoft.
2. Gao YY,Di Pascuale MA,Li W,et al.In vitro and in vivo killing of ocular Demodex by tea tree oil.Br J Ophthalmol.
2005;89(11):1468-1473.
3. Bron AJ,Tiffany JM.The contribution of meibomian disease to dry eye.Ocul Surf.2004;2(2):149-165.
4. McCulley JP,Shine WE.Meibomian gland dysfunction and the tear lipid layer.Ocul Surf.2003;1(3):97-106.
5. Wang Y,Zhang WH,Pan ZQ.Clinical investigation of chronic blepharitis and evaporative loss dry eye [in Chinese].
Zhonghua Yan Ke Za Zhi.2006;42(2):162-165.
6. Pinna A,Piccinini P,Carta F.Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction.
Cornea.2007;26(3):260-264.
7. Macsai MS.The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction.Trans
Am Ophthalmol Soc.2008;106:336-356.
8. Pavesio CE,Decory HH.Treatment of ocular inflammatory conditions with loteprednol etabonate.Br J Ophthalmol.
2008;92(4):455-459.
9. Novack GD,Howes J,Crockett RS,Sherwood MB.Change in intraocular pressure during long-term use of loteprednol etabonate.J Glaucoma.1998;7(4):2766-2769.
10. Torkildsen G,O’Brien TP.Conjunctival tissue pharmacokinetic properties of topical azithromycin 1% and moxifloxacin 0.5% ophthalmic solutions:a single-dose,randomized,open-label,active-controlled trial in healthy adult
volunteers.Clin Ther.2008;30(11):2005-2014.
11. Ianaro A,Ianlenti A,Maffia P,et al.Anti-inflammatory activity of macrolide antibiotics.J Pharmacol Exp Ther.
2000;292:156-163.
12. Luchs J.Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis.Adv
Ther.2008;25(9):858-870.
13. John T,Shah AA.Use of azithromycin ophthalmic solution in the treatment of chronic mixed anterior blepharitis.
Ann Ophthalmol (Skokie).2008;40(2):68-74.
14. Pullos AN,John T.Effect of posterior blepharitis treatment on tear meniscus.Poster presented at:The ARVO
Annual Meeting;May 4,2010;Fort Lauderdale,FL.
15. Perry HD,Doshi-Carnevale S,Donnenfeld ED,et al.Efficacy of commercially available topical cyclosporine A
0.05% in the treatment of meibomian gland dysfunction.Cornea.2006;25(2):171-175.
16. Dougherty JM,McCulley JP,Silvany RE,Meyer DR.The role of tetracycline in chronic blepharitis.Inhibition of lipase
production in staphylococci.Invest Ophthalmol Vis Sci.1991;32:2970-2975.
17. Frucht-Pery J,Sagi E,Hemo I,Ever-Hadani P.Efficacy of doxycycline and tetracycline in ocular rosacea.Am J
Ophthalmol.1993;11:88-92.
18. Yoo SE,Lee DC,Chang MH.The effect of low-dose doxycycline therapy in meibomian gland dysfunction.Korean J
Ophthalmol.2005;19:258-263.