Treatment Options for Blepharitis
BY LEO SEMES, OD, FAAO
A 44-year-old male patient who had refractive surgery (custom astigmatic LASIK) six years earlier came to the practice with a complaint of itchy eyes. BSCVA was 20/20 in each eye, and though it was slightly less uncorrected he was very pleased with his outcome. Anterior segment evaluation was remarkable for collarettes at the base of the lashes of all four lids. In addition, there was evidence of meibomian gland dysfunction (blocked duct openings, foamy tears and conjunctival injection). We diagnosed this patient with anterior and posterior blepharitis.
Managing This Patient
After discussing some treatment options, we decided on a two-week trial of Ilotycin (erythromycin ophthalmic ointment, USP, 0.5%, Dista) to be applied to the lids twice per day. Erythromycin is indicated for treating superficial ocular infections involving the conjunctiva and/or cornea as well as prophylaxis against ophthalmia neonatorum. The ointment should be applied as a one-half-inch ribbon to the affected area and can be used up to six times per day. Erythromycin has activity against a spectrum of organisms including Staph. aureus, which is often the offender. We presented this off-label use to the patient, who accepted the treatment recommendation.
The patient returned after two weeks of compliant application. Visual acuity was unchanged, and the anterior segment observations were remarkably improved. The patient stated that his eyes no longer itched and that co-workers had commented that his eyes appeared to be whiter. Clinically, the collarettes and the foamy consistency of the marginal tears were gone. Conjunctival injection had decreased.
There are many approaches to managing blepharitis. The scheme developed by Thygesson more than 60 years ago emphasized the anterior forms that related to dermatological diagnoses. These included such characterizations as eczema and mixed and angular blepharitis of the keratinized lid skin, as well as lash involvement. Recently, the focus of attention has shifted to the non-keratinized epithelium, that of the posterior lid including the meibomian glands and posterior structures.
The report of a Delphi panel (Behrens et at, 2006), convened to recommend detailed diagnostic and management strategies for patients who have "dry eyes," coined the term dysfunctional tear syndrome (DTS) to express the resultant tear problems that may make patients symptomatic. However, when we think about dry eyes or ocular surface disorders, we should be reminded by the anatomy of the lids that the lacrimal unit consists of the secretors (glands), distributors (lids) and drainage ducts.
Alternative treatments may include lid hygiene alone or in combination with oral antibiotics. Topical and oral antibiotics may be used alone, as well. Some clinicians are also now using AzaSite (azythromycin ophthalmic solution 1%, Inspire Pharmaceuticals), and early results are promising. Finally, cyclosporine 0.05% (Restasis, Allergan) has been investigated and found to have a favorable outcome for posterior blepharitis.
What you should recognize is that patients may have a variety of symptomatic descriptions of their dysfunctional tear syndrome (or even be asymptomatic) and that we have a spectrum of treatment options for them. In this case, topical erythromycin ointment was successful. CLS
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Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.