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Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 Ophthalmic Blepharitis- : A Short Note Vinod Singh1*, Rizwan Ahmad2, Mamta Farswan Singh3 1 Gurukul Kangri University, Haridwar, Uttarakhand. (India) 2 Oman Medical College, Sohar, (Oman) 3 SBS PG Institute of Biomedical Sciences & Research, Dehradun, Uttrankhand.(India) Received: 10.10.2013 Accepted:20.11.2013 Abstract: Blepharitis is a non-specific term to describe an array of inflammatory conditions involving the eyelid margin, and it is often overlooked. This may be attributed to its complex and multifactorial nature, the lack of an uncomplicated and formal definition. In Blepharitis, there is formation of scars, scales or greasy stakes at hair follicles of eyelids. Blepharitis affects the lid margins, the lash follicles, or the openings of the meibomian glands, can occur as either an acute or a chronic condition. It can affect vision by disrupting the surface of the cornea and the bulbar conjunctiva and may influence tear film composition. Despite of the high extreme of this disease, it has been poorly understood clinical entity and considered as a challenge for pharmaceutical scientists. Keywords: blepharitis, eye crusts, inflammation, eye redness. Introduction The eye is a unique window into health. It’s the only place in the body where, without surgery, we can look in and see veins, arteries, and a optic nerve. The eyes’ transparency explains why common eye diseases such as glaucoma, cataracts, and macular degeneration can be detected early with regular eye exams. Unfortunately, people get busy and delay not only eye exams but regular physicals. That’s why eye doctors sometimes discover other issues, like diabetes or high blood pressure, People like caregivers, who worry about others around them while neglecting care for themselves. Blepharitis is a chronic inflammation of the eyelid margins. It begins early in the childhood and frequently continues throughout life. Blepharitis is a descriptive term that refers to a group of disorders that produces inflammation of the lid margin and associated adnexal structures. It usually involves the eyelids and eyelashes. It can also include the glands that lubricate the lid, and the white area of the eye. Blepharitis affects the lid margins, the lash follicles, or the openings of the meibomian glands, can occur as either an acute or a chronic condition. It can affect vision by disrupting the surface of the cornea and the bulbar conjunctiva and may influence tear film composition. Blepharitis is a complicated, chronic condition that may be difficult to treat and can have an early onset with periods of remission and exacerbation. Even with an accurate diagnosis, the absence of a consensus on treatment may impact the progression, severity, and prognosis of the disease. Management of blepharitis can vary; however, treatment generally is comprised of both a pharmacological and a non pharmacological component. Despite of the high extreme of this disease, it has been poorly understood clinical entity and considered as a challenge for pharmaceutical scientists. It has been well established that microorganisms play a significant role in the pathogenesis of blepharitis.1-7 Corresponding author: Dr. Vinod Singh, Department of Pharmaceutical Sciences, Gurukul Kangri University, Haridwar, Uttarakhand. (India), Mobile: +91-9412070199, E-mail: [email protected] 1 www.gdjpr.com Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 Figure 1. Comparision depicting blepharitis and normal eye condition Figure 2. Scalp/ Crusts formation at eyelids A feeling that something is in the eye. This can cause itching, burning, redness, and swelling of the lid. May also have tearing and be sensitive to bright light. - Irritation in eye was observed if flakes from the lid fall into the eye. - Eyelashes may fall out, Formation of ulcers may take place. (Figure 4) Frequent signs and symptoms - On the eyelid, small sores may grow. Crusts may form on the edges of the eyelid (Figure 1 and 2). - On the eyelid edges, redness and greasy flakes was observed (Figure 3) - During sleep, discharge from the lid can be observed. Lids may be stuck together in the morning. - Figure 3. Greasy Flakes on the eye lid Causes Figure 4. Presence of ulcers in blepharitis Risk of blepharitis increases with some factors Seborrheic blepharitis is caused by a skin condition called seborrhea. It is similar to dandruff. - Bacterial infection of the eyelash follicles and the glands that lubricate the eye. The infection cannot be spread from one person to another. - Plugged glands on the eyelid may increase chances of blepharitis. - Allergies or lice in the eyelashes may cause blepharitis. - - 2 Skin Infection or Dermatitis of the scalp and other body parts. Exposure to allergens. Exposure to environmental irritants, such as smoke or smog. Dirty hands for most of the day may increases the chances of blepharitis. Advanced or older age. www.gdjpr.com Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 - blepharitis. Patients complains of burning sensation of eyes just after waking up called chronic conjunctivitis meibomiana. In some cases, meibomian froth, which arises from agitation of the oily secretion by blinking is present on the lid margins. Acne rosacea. Over years, several classification schemes for categorizing different types of blepharitis have been proposed. In 1946, Thygenson divided blepharitis into three etiologic types based on distinct clinical characteristics: Staphycoccal, seborreic, diplobacillary blepharitis8. McCulley et al introduced a more elaborate classification scheme based on the characteristics of eyelid, lashes, hair follicles, meibomian orifices, debris on the lid margin and corneal changes. In the McCulley classification, Blepharitis is subdivided into six groups: Staphylococcal blepharitis, Sborrheic alone, Seborrheic with staphylococcal , Seborrheic with Meibomian seborrhea, seborrheic with secondary meibomitis, and primary meibomitis9. Wilhelmus has described a clinically approach for evaluating blepharitis based on an anatomic delineation of lid margin according to the gray line. The gray line ( muscle of riolan) divides the lid into an anterior lamella ( skin and muscle) and a posterior lamella ( tarsus and conjunctiva). The eyelash follicles and associated glands of Zeiss are part of anterior lamella and meibomian glands are part of posterior lamella. Wilhelmus divided into two general categories: Anterior lid margin and posterior lid margin10. 3. Seborrheic/Staphylococcal Blepharitis Also referred to as ulcerative or mixed blepharitis, it is the least common form of blepharitis and is characterized by secondry keratoconjunctivitis, papillary and follicular hypertrophy, conjunctival injection, and mixed crusting. Ulcerative blepharitis is caused by the acute and chronic suppurative inflammation of the follicles of the lashes and the associated glands of Zeis and Moll. Caustive organism is usually staphylococcus aureus but some strains of S.epidermidis is also present. In the ulcerative blepharitis , symptoms are generally inflamed and red eyelid margins, multiple lesions surrounded by yellow pus that crusts and is removed with difficulty, Loss of lashes and necrotizing inflammation cause distortion of the eyelid margins, leading to epiphora and chronic conjunctivitis. 4. Meibomian Seborrheic Blepharitis 16 Description and classification In Meibomian Seborrheic blepharitis increased meibomian and seborrheic secretions without acute inflammation was observed. Altered meibomian secretions may lead to bulbar injection. 1. Staphylococcal Blepharitis 11,12,13,14 Usually caused by staphylococcus aureus or staphylococcus epidermidis organisms, it produces a moderately acute inflammation of relatively short duration; more prevalent in warmer climates and often occurs in middle aged females. Related hordeolum and chalazion may also occur. 5. Seborrheic Meibomianitis Blepharitis with Secondary Sporadic episodes of inflammation and meibomianitis , result in clogged meibomian glands and anterior seborrhea, producing an unstable preocular tear film (POTF). 2. Seborrheic Blepharitis 15 Part of a dermatologic condition that includes the scalp, face, and eyebrows; also called squamous blepharitis. Clinical signs include greasy, scaly lashes. Inflammation is usually minimal. Seborrheic dermatitis commonly affects the scalp, the brows, lid margin causing seborrheic blepharitis. Blephiritis is characterized by edema, hyperemia and dry flakes or oily secreations that accumulate on the eye lashes and lid margin. 6. Meibomian Keratoconjunctivitis Seborrhea is associated with staphylococcal lid infections. The Major symptoms of seborrheic blephiritis include irritation, itching , severe burning of eyes, heavy or tired feeling of eyelids, Red eyelid margins, Foreign body sensation. Meibomian gland inflammation may be imposed on seborrheic In this case, both the staphylococcal and the moraxella forms of angular blepharitis are located on the lid at the outer canthus. It is severe lid margin inflammation, which occurs in persons in their fifties, is more common in colder climates, is frequently associated with acne rosacea, and is part of a generalized sebaceous gland dysfunction which clogs the meibomian openings. 7. Angular Blepharitis17 3 www.gdjpr.com Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 Preventive measures18,19,20 1. Disappearing eyebrows - - - - Use warm-water soaks to reduce discomfort and speed healing. Apply soaks for 20 minutes, then rest at least 1 hour. Repeat as often as needed. Wash the eyelid edge and eyelashes twice a day. Use a baby shampoo diluted with some water, or a commercial eyelid cleanser. Use a washcloth wrapped around the index finger or cotton swabs. Don't rub too hard, as it can lead to irritation. Rinse with warm water and then dry the area. Avoid use of eye make-up until symptoms improves. When used, be sure to remove it each night at bedtime. Wash hands often, and dry them with clean towels. Keep face, eyelids, and scalp clean. Avoid places that have lots of dust or other irritating substances. Get treatment for any skin disorders. Control scalp problems with antidandruff shampoos. When the outer third of the brow (the part closest to the ears) starts to disappear on its own, this is a common sign of thyroid disease — either hyperthyroidism (overactive thyroid gland) or hypothyroidism (underactive thyroid gland). The thyroid is a small but critical gland that helps regulate metabolism, and thyroid hormones are among those critical to hair production. Brows tend to thin with age naturally. But with thyroid disease, the brow-hair loss isn’t evenly distributed; it’s a selective dropout on the ends. Brows are so prominent , it’s often noticed here first. Early graying is a related sign of a thyroid problem. Women are more often affected than men, and hyperthyroidism especially strikes women in their 20s and 30s. 2. A stye A small, raised, often reddish bump along the inner or outer eyelid margin is just an unsightly but innocuous stye (also called a “chalazion”). But if the spot doesn’t clear up in three months, or seems to keep recurring in the same location, it can also be a rare cancer (sebaceous gland carcinoma). Evaluation 21,22 Ocular Examination External examination of the eye, including lid structure, skin texture, and eyelash appearance has to be observed. Comparison of the eyes helps determine the severity of the inflammation Biomicroscopic examination of the lid margins, the base of the lashes, and the meibomian gland orifices and their contents are also helpful. Examination of the tear film for lipid layer abnormalities, palpebral and bulbar conjunctiva is to be taken into consideration. Actual styes are plugged-up oil glands at the eyelash follicle. Fairly common, they tend to clear up within a month. A cancerous cyst that mimics a stye, on the other hand, doesn’t go away. 3. Bumpy yellowish patches on the eyelid Xanthelasma palpebra, the medical name for these tiny yellow bumps, are usually a warning for high cholesterol contents. They’re also called “cholesterol bumps” — they’re basically fatty deposits. These are quite small bumps. Available Treatment Options - - Lid hygiene (e.g., warm, moist compresses, commercial lid scrub) Scalp and eyebrow hygiene (selenium antidandruff shampoo) Tear supplements to alleviate symptoms and reestablish ocular surface integrity Antibiotic eyedrops or ointment (e.g., erythromycin, bacitracin, polymyxin-bacitracin, gentamicin, tobramycin) to control infection Massage/expression of meibomian glands Topical antibiotic/steroid ointment or oral tetracycline/doxycycline for meibomianitis 4. Burning eyes, blurry vision while using a computer While using computer, eyestrain is partly caused by the lack of contrast on a computer screen (compared with ink on paper) and the extra work involved in focusing on pixels of light. What’s more, by midlife the eyes lose some of their ability to produce lubricating tears. Irritation sets in, adding to blurriness and discomfort. Does the problem worsen in the afternoon (when the eyes tend to become drier)? Is it worse when you’re reading fine print (more eyestrain)? General visible symptoms not to be overlooked 23, 24 4 www.gdjpr.com Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 Sometimes the problem is made worse by a fan positioned so it blows right in the face. If it is possible, Reduce glare by closing window shades, use antireflective coating for your glasses. Flat-panel LCD display screens (like those on laptops) cause less eyestrain than older models. Keep reference material close to the same height as your monitor, giving your eyes a break from having to refocus so much. liver can’t process. Skin can also turn yellowish when a person consumes too much beta carotene — found in carrots — but in those cases the whites of the eyes remain white. 9. Brown spot on the eyelid Most malignant eyelid tumors are basal cell carcinoma. When such a tumor appears as a brown spot, then — as with any other form of skin cancer — it’s more likely to be malignant melanoma. 5. Increasing gunk in the eye Elderly, fair-skinned people are at highest risk. Look especially at the lower eyelid. The bump may look pearly, with tiny blood vessels. If the bump is in the eyelash area, some eyelashes may be missing. Blepharitis — inflammation of the eyelids, especially at the edges — can have several causes. Two of them, surprisingly, are conditions better associated with other body parts: scalp dandruff and acne rosacea (which causes flushed red skin, usually in the faces of fairskinned women at midlife). The eyes may also feel irritated, as if piece of glass is present in eye. They may burn, tear, or feel dry. The crusty debris tends to gather in the lashes or the inner corners of the eyes, or even on the lids. 10. Eyes that seem to bulge The Cause of protruding eyes is hyperthyroidism (overactivity of the thyroid gland), known as Graves’ disease. Some people inherit a tendency toward eyes that bulge, so if the appearance seems to run in a family so maybe it is not hyperthyroidism. The person may not blink often and may seem to be staring at you. Because the condition develops slowly, it’s sometimes first noticed in photos or by the occasional visitor rather than by someone who lives with the person every day. 6. A small blind spot in your vision An ocular migraine / ophthalmic migraine/ optical migraine/ migraine aura produces this disturbed vision, with or without an accompanying headache. Changes in blood flow to the brain are thought to be the cause. The visual distortion starts in the center of the field of vision. It might appear as a bright dots , or a line that can seem to move and disrupt your ability to see properly, as if you were looking through a pocked or cracked window. It’s painless and causes no lasting damage. Patients seem to have different triggers (ranging from chocolate, caffeine, and alcohol to stress) for headache possibly severe enough to cause nausea. 11. Sudden double vision, dim vision, or loss of vision These are the visual warning signs of stroke. The other signs of stroke include sudden numbness or weakness of the arm or leg or face, typically on just one side of the body; trouble walking because of dizziness or loss of balance or coordination; slurred speech; or bad headache. 7. Itchy and Red eyes In a large stroke caused by a blood clot or bleeding in the brain, these symptoms happen all at once. In a smaller stroke caused by narrowed arteries, they can occur across a longer period of minutes or hours. Many things can irritate eyes, but itchiness accompanied by sneezing, coughing, sinus congestion, and a runny nose, usually screams “I’m allergic!” When the eyes are involved, the trigger is usually airborne, like pollen, dust, or animal dander. An eye allergy can also be caused by certain cosmetics or ointments. 12. Dry eyes sensitive to light Sjogren’s syndrome is an immune system disorder. It impairs the glands in the eyes and mouth that keep them moist. Sjogren’s usually affects women over age 40 with autoimmune disorders such as rheumatoid arthritis or lupus. Usually the eyes and mouth are affected together. The person may also have vaginal dryness, dry sinuses, and dry skin. Because of a lack of saliva, it can be difficult to chew and swallow. 8. Yellowish eye Generally observed in patients suffering jaundice: Newborns with immature liver function and adults with problems of the liver, gallbladder, or bile ducts, including hepatitis and cirrhosis. The yellow in the white part of the eye (the sclera) is caused by a buildup of bilirubin, the by-product of old red blood cells the 5 www.gdjpr.com Vinod Singh et al., Guru Drone Journal of Pharmacy and Research, 2013;1(1):1-6 13. Sudden difficulty closing one eye, inability to control tears in it 9. Bell’s palsy is an impairment of the nerve that controls facial muscles (the seventh cranial nerve), causing temporary paralysis in half the face. It sometimes follows a viral infection (such as shingles) or a bacterial infection (such as Lyme disease). Diabetics and pregnant women are also at higher risk. Half of the entire face, not just the eye, is affected. Effects vary from person to person, but the overall effect is for the face to appear droopy and be weak. The eyelid may droop and be difficult or impossible to close, and there will be either excessive tearing or an inability to produce tears. 10. 11. 12. 13. 14. 15. 16. References 1. 2. 3. 4. 5. 6. 7. 8. P Thygeson, Etiology and treatment of Blephiritis. A study in military personnel, Arch Ophthalmol, 1946, 36, 445- 457. P Thygenson, Bacterial factors in chronic catarrhal conjunctivitis, Arch Ophthalmol 1937, 18, 373387. J.H Allen, Staphylocccic conjunctivitis, Am J Ophthalmol, 1937, 20, 1025- 1031. G.Smolin,M.Okumoto, Staphylococcal Blepharitis, Arch Ophthalmol, 1977, 95, 812-816. MJ. Valenton, M. Okumoto, Toxixn producing strains of staphylococcus epidermis (albus), Arch Ophthalmol, 1973, 89, 186- 1890. JP. McCulley, JM. Dougherty, DG. Deneau, Classification of chronic blepharitis, Ophthalmology, 1982, 89, 1173- 1180. LR. Groden, B. Murpy, J. Rodnite et al., Lid Flora in Blephararitis, Cornea. 1991, 10, 50- 53. P. Thygenson, Bacterial factors in chronic catarrhal conjunctivitis, Arch ophthalmol, 1946, 36, 445457. 17. 18. 19. 20. 21. 22. 23. 24. 6 JP. McCulley, JM. Dougherty, DG. Deneau, Classification of chronic Blepharitis, Ophthalmology,1982, 89,1173-1180. KR. Wilhelmus, Inflammatory disorders of the eyelid margins and eye lashes, Ophthalmol Clin North America, 1992,5,187-194. R Scott Lowery (Jun 17, 2011). "Adult Blepharitis".Medscape.Retrieved 21 December 2012. James Garrity (August 2012). "Blepharitis". The Merck Manual. Retrieved 21 December 2012. "Blepharitis, Stye and Chalazion". University of Illinois College of Medicine. Retrieved 21 December 2012. "Blepharitis". Angeles Vision Clinic. Retrieved 21 December 2012. www.patient.co.uk/health/blepharitis.htm www.aoa.org/documents/optometrists/QRG10A.pdf www.one.aao.org/image/angular-blepharitis-2 www.webmd.com/eye-health/blepharitis www.healthcommunities.com/blepharitis/remedies -for-blepharitis.shtml www.articlesbase.com/wellness-articles/treatmentfor-blepharitis-5431666.html F. Karimian, S.Zarei- Ghanavati, K. Jadidi, A. Lotfi-Kian, Microbial evaluation of chronic Blepharitis among Iranian veterans exposed to mustard gas: A case – controlled study, Cornea, 2011,30(6), 620-623. N. Asano-Kato, K Fukagawa K, Tsubota K, Urayama K, S. Takahashi, H. Fujishima, Quantitative evaluation oa atopic Blepharitis by scoring of eyelid conditions and measuring the water content of skin and evaporation from eye lid surface, Cornea, 2001, 20(3), 255-259. www.webmd.com/eye-health/features/what-youreyes-say-about-your-health www.merckmanuals.com/professional/eye_disorde rs/symptoms_of_ophthalmic_disorders/blurred_vis ion.html www.gdjpr.com