Anterior Blepharitis
Clinical & Refractive Optometry is pleased to
present this continuing education (CE) article by Dr. Ron
Melton and Dr. Randall Thomas entitled Blepharitis. In order
to obtain a 1-hour Council of Optometric Practitioner Education
(COPE) approved CE credit.
From:Clinical & Refractive Optometry 15:4, 2004
Subjective
A 26-year-old white male presents with a history of irritation
to both eyes for the past several years. He notices some
crusting material to the lids upon awakening and complains
about his eyes and lids always red. He has tried a number
of over-the-counter (OTC) eye drops with no noticeable improvement
in his symptoms.
Objective
- Visual acuity (VA): OU 6/6 (20/20)
- Gross observation: generalized redness to the lid margins
(Fig. 1)
- Lids: 2+ erythema to the anterior lid margins (Fig. 2)'
2+ scales centered around the base of the lashes (collarettes)
with scattered flakes of staphylococcal debris (Fig. 3)
- Conjuctiva; 1+ hyperenia to bulbar conjunctiva
- Cornea: clear OU; decreased tear break-up time (BUT) to
5 sec OU
 |
Fig. 1 This patient presented
with a generalized redness to the lid margins,
not an uncommon clinical finding. |
 |
Fig. 2 The anterior lid margins show
erythema and moderate madarosis of the lower
lashes. |
 |
Fig. 3 The scales are centered around
the base of the lashes (collarettes) with
scattered flakes of staphylococcal debris. |
Assessment
Bilateral anterior staphylococcal blepharoconjunctivitis with
secondary dry eye
Plan
- Patient education regarding the chronic nature of this
eyelid disorder and the self-care involved in maintaining
control of his symtoms
- Warm compresses b.i.d. for 5 min prior to gently scrubbing
the lids and lashes with an OTC commercially available lid
scrub
- Bacitracin ophthalmic ointment applied to the lids at bedtime
for 1 month
- TheraTears q.i.d. for 1 month
- Follow-up in one month. Significant improvement noted in
the patient's symptoms. The clinical picture shows the lids
and conjunctiva to have less than Grade I injection and the
lashes are clean. Continue the warm compresses and lid scrubs
daily and the artificial tears q.i.d. OU indefinately.
Comments: All clinicians have been taught that
lid hygiene is the key to the management of blepharitis. No
matter the type of blepharitis, warm compresses followed by
lid scrubs are crucial in reducing patient complaints. An educational
handout helps reinforce the treatment plan.
If the symptoms and clinical picture are severe enough, then
using a combination antibiotic-steroid ointment such as tobrarnycin/
dexamethasone (Tobradex) for the first week followed by the
straight antibiotic ointment for a month may be appropriate.
It is important if prescribing this treatment method to educate
the patient about the potential, but rare side-effects of long-term
steroid use (since patients often prefer to continue the steroid-containing
product due to the good response).
Posterior Blepharitis (meibomianitis)
Subjective
A 58-year-old white female presents with a history of chronic
redness to the eyes (Fig. 4) with an associated burning sensation.
She often has a "film" over her vision. This condition
has persisted for years. She has seen several eye doctors
during this time with little or no relief of her symptoms.
 |
Fig. 4 It is not unusual for a patient
with posterior blepharitis (meibomianitis) to present
with a history of chronic redness to the eyes with
an associated burning sensation. |
Objective
- Visual acuity (VA): OD 6/7.5 (20/25) OS 6/9 (20/30)
- Lids: thickened eyelid margins with erythema of the posterior
lid margins with mild madarosis (Fig. 5); oily collection
on the lashes; meibomian gland orifices are clogged and expressed
meibomian secretions have a toothpaste-like consistency
 |
Fig. 5 The posterior lid
margins are thickened with erythema and mild
madarosis. |
- Oily tear film is present with 5 to 8 sec BUT OU
- Conjunctiva: 2+ bulbar conjunctival injection OU
- Cornea: clear OU
Assessment
Posterior blepharitis (meibomianitis) with compromised tear
film function
Plan
- Educate the patient about the chronic nature of this
eye condition and the importance of compliance with the
recommended treatment
- Warm compresses for 5 min q.i.d., followed by fingertip
massage of the lids, and then by scrubbing and cleaning with
a commercially available eyelid cleaner for 1 month
- Rx tobramycin/dexamethasone eyedrops q.i.d. OU x 5 days,
then b.i.d. OU x 5 days
- Recommend TheraTears q.i.d. OU until recheck in 1 month
- Follow-up one month: Conjunctiva shows less injection of
the lids, and lashes are cleaner, yet the patient remains
symptomatic. Continue the TheraTears q.i.d. OU and lid hygiene
with warm compresses and scrubs b.i.d. OU. Add doxycycline
100mg tablets once daily for 2 weeks, followed by 50 mg per
day for 3 to 6 months
- Follow-up at one more month: Patient states "my eyes
feel the best they have felt in years." Continue the
doxycycline for 5 months along with artificial tears and
lid hygiene. At the 6th month follow up visit stop the doxycycline;
if symptoms return, continue the doxycycline 50 mg q.d. for
another 3 months. Continue the warm compresses and lid hygiene
indefinately.
Comments: The most important step in the treatment
of posterior blepharitis is warm compresses. This decongests
the constipated oil glands so drainage of the glands is enhanced.
This process can be accomplished in many different ways, ranging
from simply putting a wash cloth under warm water then squeezing
it out, to wrapping a microwaved potato in a washcloth and
holding it against the lids.
The use of a tetracycline class antibiotic is helpful in most
cases of persistent posterior blepharitis. As well as being
antibacterial, this class of antibiotic inhibits the liberation
of fatty acids by blocking bacterial lipase. Doxycycline 100
mg once daily for 1 month then 50 mg q.d. for several months
is commonly used to manage posterior blepharitis. Doxycycline
should not be used in pregnant women, nursing mothers, or children
under eight years of age. They can also cause gastrointestinal
intolerance, photo-sensitization, and Candida vaginitis. An
alternative medication to doxycycline is erythromycin, with
a starting dose of 250 mg q.i.d., p.o.
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