Download What`s New in Oculoplastics?

What’s New in Oculoplastics?
Blepharitis and Related Disorders
Dr. Gamal Seif, MD, MSc, FRCSC
Department of Ophthalmology,
Oakville Trafalgar Memorial Hospital
Disclosure
Relationships with commercial
interests:
- Grants/Research Support: None
- Speakers Bureau/Honoraria: None
- Consulting Fees: None
- Other: None
Outline




Eyelid anatomy
Signs and symptoms
Aetiology
Treatments
◦ Hot compresses
 Warm/moist towel, blow mist, mask etc.
◦ Lid wipes
 Baby Shampoo, Lid Wipes, Cliradex
◦ Fancy devices
 Lipiflow, Intense pulse light, Bleaphasteam, MG expression,
Probing
◦ Drugs
 Tetracyclines, aziyhromycin, clarithromycin
Introduction – Eyelid Anatomy
© 2016 - marineyes.com
Blepharitis
Idiopathic chronic inflammatory disorder
of eyelids
 Usually isolated near base of eyelashes
around eyelashes
 Causes, itching, burning, eye main, FB
sensation, crusting around eyes
 Symptoms usually worse in am (as
opposed to dry eyes in pm)

Blepharitis- Signs

Anterior
◦ Crusting, redness, thickened eyelid margins
© 2016 – WillsEye.com
2016 - Wikicommons
Blepharitis- Signs

Posterior
◦ Inspissated oil glands (meibomian gland
dysfunction)
© 2016 eyeplastics.com
Blepharitis - Epidemiology
Few studies available
 Spanish cross-sectional study reported
asymptomatic and symptomatic meibomian
gland dysfunction of 21.9% and 8.6% of
individuals, respectively.
 US survey = 37-47% of patient with signs of
blepharitis
 Average age is 50, younger and more females
with streptococcal disease (mean
42)].[9][10]

Blepharitis- Aetiologies
Idiopathic
 Ocular Rosacea
 Staphylococcal Infection
 Demodex
 Contact lens wear?
 Glaucoma Meds?

Rosacea
© 2016 - dermas.info
Staphylococcal Infection

Hordeolum: Acute infection involving
sebaceous glands
◦ Glands of Zeiss (external hordeolum, aka stye)
◦ Meibomian glands (internal hordeolum)
2016 - Wikicommons
Demodex
• Most common ectoparasites in
Humans
• Folliculorum – Hair follicles
• Brevis – Sebaceous glands
• Prevalence around 50% by 20 y/o,
almost all elderly males
• Older Age, oily skin, and facial acne
increased prevalence
© 2016 askjpc.org
© 2016 contactlensupdate.com
Demodex
Debris and waste  cylindrical dandruff,
(pathognomonic for mites infestation)
 Block the sebaceous ducts, irritate the
eyelid margin, and induce epithelial
hyperplasia and hyperkeratinization
 The cytoskeleton  foreign body

◦ granulomatous reaction  chalazia
◦ Elicit an inflammatory/immune response
Blepharitis Treatment

Lid wipes
◦ Baby Shampoo
◦ Lid Wipes ®
◦ Cliradex ® (Terpinen- 4-ol (T4O)
 BID for at least 6 weeks to cover two 2 life cycles.
Blepharitis Treatment

Hot compresses – Are all compresses the
same?
◦ Hot face cloth towel (dry vs wet)
◦ EyeGiene®
◦ MGDRx EyeBag®
MGD - Treatment

Blephasteam ®



Wet chamber warming goggles
10 min three times daily
Viliani et al, Int Ophthalmol (2015) 35:319–323
 Showed improvement in TBUT and OSDI in
patients that did not respond to warm
compresses
MGD - Treatment

Lipiflow
MGD - Treatment

Intense pulse light
◦ light therapy over a broad range of
wavelengths.
◦ Warms MG and constriction of blood vessels
◦ Usually monthly doses x 3-5 months then
every 6 months
MGD - Treatment

MG probing
◦ Pioneered by Steven Maskin, MD
◦ Direct probing of individual meibomian glands
with probe to physically opening up the
occlusion caused by MGD
◦ Requires local aesthetic
◦ Maskin probe
What modality is best?
All products are supported by case series
showing improved patient symptoms,
TBUT and ASDI scores.
 Few Head to head comparisons with
conflicting results

MGD – Treatment - Drugs

Topical
◦ Erythromycin
◦ Tobradex

Oral
◦ Tetrocyclines
◦ Azithromycin/ Clarithromycin
◦ Omega 3 supplementation

Injections
◦ Steroids
References

Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007; 26:136–143.

Nenoff, P., Handrick, W., Krüger, C., Herrmann, J., Schmoranzer, B., & Paasch, U. (2009). [Ectoparasites. Part 2: Bed bugs, Demodex, sand fleas and
cutaneous larva migrans]. Der Hautarzt; Zeitschrift Für Dermatologie, Venerologie, Und Verwandte Gebiete, 60(9), 749–57– quiz 758–9.
http://doi.org/10.1007/s00105-009-1821-2

Satjawatcharaphong, P., Ge, S., & Lin, M. C. (2015). Clinical Outcomes Associated with Thermal Pulsation System Treatment. Optometry and Vision
Science : Official Publication of the American Academy of Optometry, 92(9), e334–41. http://doi.org/10.1097/OPX.0000000000000670

Schear, M. J., Milman, T., Steiner, T., Shih, C., Udell, I. J., & Steiner, A. (2015). The Association of Demodex with Chalazia: A Histopathologic Study
of the Eyelid. Ophthalmic Plastic and Reconstructive Surgery. http://doi.org/10.1097/IOP.0000000000000500

Sik Sarman, Z., Cucen, B., Yuksel, N., Cengiz, A., & Caglar, Y. (2016). Effectiveness of Intraductal Meibomian Gland Probing for Obstructive
Meibomian Gland Dysfunction. Cornea, 35(6), 721–724. http://doi.org/10.1097/ICO.0000000000000820

Thode, A. R., & Latkany, R. A. (2015). Current and Emerging Therapeutic Strategies for the Treatment of Meibomian Gland Dysfunction (MGD).
Drugs, 75(11), 1177–1185. http://doi.org/10.1007/s40265-015-0432-8

Toyos, R., McGill, W., & Briscoe, D. (2015). Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year
retrospective study. Photomedicine and Laser Surgery, 33(1), 41–46. http://doi.org/10.1089/pho.2014.3819

Uzunosmanoglu, E., Mocan, M. C., Kocabeyoglu, S., Karakaya, J., & Irkec, M. (2016). Meibomian Gland Dysfunction in Patients Receiving Long-Term
Glaucoma Medications. Cornea. http://doi.org/10.1097/ICO.0000000000000838

Vegunta, S., Patel, D., & Shen, J. F. (2016). Combination Therapy of Intense Pulsed Light Therapy and Meibomian Gland Expression (IPL/MGX) Can
Improve Dry Eye Symptoms and Meibomian Gland Function in Patients With Refractory Dry Eye: A Retrospective Analysis. Cornea, 35(3), 318–
322. http://doi.org/10.1097/ICO.0000000000000735

Villani, E., Garoli, E., Canton, V., Pichi, F., Nucci, P., & Ratiglia, R. (2015). Evaluation of a novel eyelid-warming device in meibomian gland dysfunction
unresponsive to traditional warm compress treatment: an in vivo confocal study. International Ophthalmology, 35(3), 319–323.
http://doi.org/10.1007/s10792-014-9947-3

Wang, M. T. M., Gokul, A., & Craig, J. P. (2015a). Temperature profiles of patient-applied eyelid warming therapies. Contact Lens & Anterior Eye :
the Journal of the British Contact Lens Association, 38(6), 430–434. http://doi.org/10.1016/j.clae.2015.06.002

Wang, M. T. M., Jaitley, Z., Lord, S. M., & Craig, J. P. (2015b). Comparison of Self-applied Heat Therapy for Meibomian Gland Dysfunction.
Optometry and Vision Science : Official Publication of the American Academy of Optometry, 92(9), e321–6.
http://doi.org/10.1097/OPX.0000000000000601

Wladis, E. J., Bradley, E. A., Bilyk, J. R., Yen, M. T., & Mawn, L. A. (2016). Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A
Report by the American Academy of Ophthalmology. Ophthalmology, 123(3), 492–496. http://doi.org/10.1016/j.ophtha.2015.10.062

Yeo, S., Tan, J. H., Acharya, U. R., Sudarshan, V. K., & Tong, L. (2016). Longitudinal Changes in Tear Evaporation Rates After Eyelid Warming
Therapies in Meibomian Gland Dysfunction. Investigative Ophthalmology & Visual Science, 57(4), 1974–1981. http://doi.org/10.1167/iovs.16-19088

Zhang, L., Su, Z., Zhang, Z., Lin, J., Li, D.-Q., & Pflugfelder, S. C. (2015). Effects of azithromycin on gene expression profiles of proinflammatory and
anti-inflammatory mediators in the eyelid margin and conjunctiva of patients with meibomian gland disease. JAMA Ophthalmology, 133(10), 1117–
1123. http://doi.org/10.1001/jamaophthalmol.2015.2326
References

Al-Hity, A., & Lockington, D. (2016). Oral azithromycin as the systemic treatment of choice in the treatment of meibomian gland disease. Clinical &
Experimental Ophthalmology, 44(3), 199–201. http://doi.org/10.1111/ceo.12666

Baudouin, C., Messmer, E. M., Aragona, P., Geerling, G., Akova, Y. A., Benítez-Del-Castillo, J., et al. (2016). Revisiting the vicious circle of dry eye
disease: a focus on the pathophysiology of meibomian gland dysfunction. The British Journal of Ophthalmology, 100(3), 300–306.
http://doi.org/10.1136/bjophthalmol-2015-307415

Bhargava, R., Chandra, M., Bansal, U., Singh, D., Ranjan, S., & Sharma, S. (2016). A Randomized Controlled Trial of Omega 3 Fatty Acids in Rosacea
Patients with Dry Eye Symptoms. Current Eye Research, 1–7. http://doi.org/10.3109/02713683.2015.1122810

Cheng, A. M. S., Sheha, H., & Tseng, S. C. G. (2015). Recent advances on ocular Demodex infestation. Current Opinion in Ophthalmology, 26(4),
295–300. http://doi.org/10.1097/ICU.0000000000000168

Craig, J. P., Chen, Y.-H., & Turnbull, P. R. K. (2015). Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction.
Investigative Ophthalmology & Visual Science, 56(3), 1965–1970. http://doi.org/10.1167/iovs.14-15764

Finis, D., König, C., Hayajneh, J., Borrelli, M., Schrader, S., & Geerling, G. (2014). Six-month effects of a thermodynamic treatment for MGD and
implications of meibomian gland atrophy. Cornea, 33(12), 1265–1270. http://doi.org/10.1097/ICO.0000000000000273

Gao, Y.-Y., Di Pascuale, M. A., Elizondo, A., & Tseng, S. C. G. (2007). Clinical treatment of ocular demodecosis by lid scrub with tea tree oil.
Cornea, 26(2), 136–143. http://doi.org/10.1097/01.ico.0000244870.62384.79

Golebiowski, B., Badarudin, N., Eden, J., You, J., Hampel, U., & Stapleton, F. (2016). Does endogenous serum oestrogen play a role in meibomian
gland dysfunction in postmenopausal women with dry eye? The British Journal of Ophthalmology. http://doi.org/10.1136/bjophthalmol-2016-308473

Greiner, J. V. (2016). Long-Term (3 Year) Effects of a Single Thermal Pulsation System Treatment on Meibomian Gland Function and Dry Eye
Symptoms. Eye & Contact Lens, 42(2), 99–107. http://doi.org/10.1097/ICL.0000000000000166

Hu, Q., & Wang, Y. (2001). [Investigation on the prevalence of human Demodex among 2,248 medical students in inner Mongolia]. Zhongguo Ji
Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi = Chinese Journal of Parasitology & Parasitic Diseases, 19(4), 239–240.

Kashkouli, M. B., Fazel, A. J., Kiavash, V., Nojomi, M., & Ghiasian, L. (2015). Oral azithromycin versus doxycycline in meibomian gland dysfunction: a
randomised double-masked open-label clinical trial. The British Journal of Ophthalmology, 99(2), 199–204. http://doi.org/10.1136/bjophthalmol2014-305410

Koo, H., Kim, T. H., Kim, K. W., Wee, S. W., Chun, Y. S., & Kim, J. C. (2012). Ocular surface discomfort and Demodex: effect of tea tree oil eyelid
scrub in Demodex blepharitis. Journal of Korean Medical Science, 27(12), 1574–1579. http://doi.org/10.3346/jkms.2012.27.12.1574

Liang, Q., Liu, H., Guo, Y., Cui, R., Li, B., Wang, N., & Labbe, A. (2015). [Clinical evaluation of a thermodynamic treatment system for meibomian
gland dysfunction]. [Zhonghua Yan Ke Za Zhi] Chinese Journal of Ophthalmology, 51(12), 924–931.

Liu, Y., Kam, W. R., & Sullivan, D. A. (2016). Influence of Omega 3 and 6 Fatty Acids on Human Meibomian Gland Epithelial Cells. Cornea.
http://doi.org/10.1097/ICO.0000000000000874

Liu, Y., Kam, W. R., Ding, J., & Sullivan, D. A. (2015). Can tetracycline antibiotics duplicate the ability of azithromycin to stimulate human meibomian
gland epithelial cell differentiation? Cornea, 34(3), 342–346. http://doi.org/10.1097/ICO.0000000000000351
References




Ma, X., & Lu,Y. (2016). Efficacy of Intraductal Meibomian Gland Probing
on Tear Function in Patients With Obstructive Meibomian Gland
Dysfunction. Cornea, 35(6), 725–730.
http://doi.org/10.1097/ICO.0000000000000777
Machalińska, A., Zakrzewska, A., Adamek, B., Safranow, K., Wiszniewska,
B., Parafiniuk, M., & Machaliński, B. (2015a). Comparison of
Morphological and Functional Meibomian Gland Characteristics
Between Daily Contact Lens Wearers and Nonwearers. Cornea, 34(9),
1098–1104. http://doi.org/10.1097/ICO.0000000000000511
Machalińska, A., Zakrzewska, A., Markowska, A., Safranow, K.,
Wiszniewska, B., Parafiniuk, M., & Machaliński, B. (2015b). Morphological
and Functional Evaluation of Meibomian Gland Dysfunction in Rosacea
Patients. Current Eye Research, 1–6.
http://doi.org/10.3109/02713683.2015.1088953
Murakami, D. K., Blackie, C. A., & Korb, D. R. (2015). All Warm
Compresses Are Not Equally Efficacious. Optometry and Vision
Science : Official Publication of the American Academy of Optometry,
92(9), e327–33. http://doi.org/10.1097/OPX.0000000000000675