As you hunker down to read this sitting in your test room between appointments, sitting in the break room at lunch or sitting at home after your clinic has ended, your first thought upon scanning the title of this article (perhaps after scoffing at the cacophony of eye puns) is likely ‘not another blepharitis article!’ I do not blame you and I would have to agree with you. Over the last few years there has been a deluge of blepharitis-based literature thrown in our direction. Whether it is journal articles, lectures at our plethora of industry conferences or marketing materials for the ever-expanding range of blepharitis wipes, lotions and potions that appear on the market on a seemingly weekly basis, there has been an undoubted surge in blepharitis communications. However, I am also confident that earlier in the day you will have encountered at least a handful of patients suffering from some form of dry eye or lid margin disease.
Background
There have been many factors correlated with dry eye disease (DED) including age;1 gender;2 reduced or incomplete blinking;3 eye lid laxity;4 contact lens wear;5 allergic conjunctivitis;6 dietary imbalances7,8 including reduced omega III intake,9-12 vitamin A deficiency13 and vitamin D deficiency;14 systemic medications including anti-histamines,6 anti-depressants,15 beta blockers16 and diuretics;17 topical medications such as glaucoma drops;18 systemic inflammatory diseases including rheumatoid arthritis,19 fibromyalgia,20,21 systemic lupus erythematosus,22 psoriatic arthritis,23 Sjögren’s syndrome,24 scleroderma25 and chronic hepatitis C;26 HIV;27 depression;28 sex steroid hormone dysfunctions including menstrual cycle irregularity,29 pregnancy, lactation, contraceptive use, reduced androgen levels, exogenous oestrogen use, complete androgen insensitivity syndrome,30-32 premature ovarian failure,33 polycystic ovarian syndrome,34 hormone replacement therapy,35 ovariectomy36 and hysterectomy37 and environmental factors such as digital device use, high altitude, dry climate and air conditioning.38 And this list is by no means exhaustive.
However, the 2011 International Workshop on Meibomian Gland Dysfunction (MGD) concluded that blepharitis and in particular MGD may well be the leading cause of DED throughout the world.39-40 This is corroborated by a 2012 study suggesting that the most common form of dry eye is evaporative and that 86% of dry eye patients have MGD.41 Furthermore, MGD prevalence in adults in the general population has been reported to range from 30.5% to 68.3%.42,43 Such statistics are highly suggestive that within our role as primary care givers and gatekeepers to ophthalmology we will spend a significant percentage of our clinical time dealing with DED related to blepharitis and MGD. It would therefore be advantageous to the proactive practitioner and certainly to any optometrist seeking to offer a specialist dry eye service to be well versed in the nuances of blepharitis and MGD, as well as the innumerable variety of other lid margin disorders that can occur and subsequently disrupt the normal anatomy and physiology of the delicate ocular adnexa and tear film. This article will focus primarily on blepharitis and MGD.
Definition
In short, blepharitis is defined as an inflammatory process affecting the lid margins, the lash follicles, and/or the openings of the meibomian glands. It 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.44
Anatomical classification of blepharitis
Blepharitis can be classified both anatomically and by aetiology.
Blepharitis is most commonly divided anatomically into anterior, posterior, mixed and angular forms. Anterior marginal blepharitis (also known as anterior lid margin disease) refers to inflammation of the eyelash and hair follicles; posterior marginal blepharitis (also known as posterior lid margin disease) involves the meibomian glands and orifices; mixed anterior and posterior marginal blepharitis involves elements of both conditions; angular blepharitis usually involves the eyelid at the outer canthus.45
Aetiological classification
Staphylococcal blepharitis
Usually caused by Staphylococcus aureus or Staphylococcus epidermidis organisms. This bacterium is commonly found in low numbers on the skin, typically causing no harm. However, in some people, it seems this bacterium causes a localised infection of the eyelids producing a moderately acute inflammation of relatively short duration. It is not known exactly why this happens in certain individuals, but is likely due to response to one of the following;
1 direct infection
2 reaction to the staphylococcal exotoxin
3 allergic response to staphylococcal antigens.
It is more prevalent in warmer climates and often occurs in middle-aged females. Related hordeolum and chalazion may also occur.46
Seborrhoeic blepharitis
Closely linked to or part of seborrhoeic dermatitis, a dermatologic condition that affects the scalp, face, and eyebrows; can also be called squamous blepharitis. In seborrhoeic dermatitis, the affected skin becomes oilier than normal and becomes scaly. This can lead to severe dandruff and on occasion a rash on the face or upper body. The underlying cause of seborrhoeic dermatitis is not clear, but a type of yeast called Malassezia furfur is involved. The yeast lives in the oil of human skin in most adults and is under normal circumstances harmless. However, in some individuals it triggers an inflammatory reaction leading to seborrhoeic blepharitis. Clinical signs include greasy, scaly lashes. Inflammation is usually minimal.47
Seborrhoeic/staphylococcal blepharitis
Also referred to as ulcerative or mixed blepharitis, it is the least common form of blepharitis and is characterised by secondary keratoconjunctivitis, papillary and follicular hypertrophy, conjunctival injection, and mixed crusting.48
Meibomian seborrhoeic blepharitis
Can be identified by the presence of increased meibomian and seborrhoeic secretions without acute inflammation. Altered meibomian secretions may lead to bulbar injection.49
Seborrhoeic blepharitis with secondary meibomianitis
Similar to seborrhoeic blepharitis, it has sporadic episodes of inflammation and meibomianitis that result in clogged meibomian glands and anterior seborrhoea, producing an unstable preocular tear film.50
Meibomian keratoconjunctivitis
The most severe lid margin inflammation, which typically occurs in persons in their 50s, is more common in colder climates, is frequently associated with acne rosacea, and is part of a generalised sebaceous gland dysfunction which clogs the meibomian openings.51
Table 1: Classification of MGD
MGD can be further sub-classified (see table 1) into two major categories based on meibomian gland secretion as follows;
1 low-delivery states – Low-delivery states can be further sub-classified as hyposecretory (decreased meibum delivery due to abnormalities in meibomian glands with remarkable obstruction) or obstructive (due to terminal duct obstruction).
2 high delivery states. High delivery hypersecretory MGD is characterised by the release of a large volume of lipid at the lid margin that becomes visible on application onto the tarsus during examination.52
Angular blepharitis
Both the staphylococcal and the moraxella forms of angular blepharitis are located on the lid at the outer canthus.53
Demodicosis (demodex blepharitis)
Is an inflammatory reaction to the two most common ectoparasites in humans – Demodex folliculorum and Demodex brevis.54 Demodex folliculorum primarily inhabits the infundibular region of hair follicles, whereas Demodex brevis usually resides in the deeper sebaceous ductus and meibomian glands.55 Demodex infestations are believed to cause blepharitis by several mechanisms;
1 cylindrical dandruff in the eyelash follicle caused by epithelial hyperplasia and reactive hyperkeratosis due to mechanical damage
2 tear film layer insufficiency caused by blocked meibomian gland orifices
3 transport of bacteria such as streptococcus and staphylococcus along with the parasite resulting in inflammation caused by bacterial antigens
4 a hypersensitivity reaction due to the parasite’s proteins.56 Studies have shown that demodex populations increase with age thus degrading the tear film layer, promoting inflammation and resulting in ocular symptoms.57,58
Diagnosis of blepharitis and MGD
The diagnosis of blepharitis and MGD should be conducted using tests and clinical examination techniques performed in a systematic order that minimises the extent to which one test influences the results of the tests that follow. A series of tests that are recommended for use in the diagnosis of MGD and in MGD-related disorders, including evaporative dry eye, is presented in table 2.
Table 2: Specialised and non-specialised tests for MGD and MGD-related disease
A suitable sequence of tests to perform in a general practice for the diagnosis of MGD-related disease is as follows:
1 Symptom questionnaire
2 Measurement of blink rate and blink interval
3 Measurement of lower tear meniscus height
4 Instillation of fluorescein and measurement of tear film breakup time (TFBUT) and ocular protection index (OPI)
5 Grading of corneal and conjunctival staining
6 Schirmer 1 test or phenol red thread test
7 Quantification for morphologic lid features
8 Quantification of meibum expressibility and quality
The graded scores as shown in table 3 for each test can be used to make a more accurate diagnosis, help guide the required treatment and be used to monitor the disease during treatment. Practices with additional diagnostics equipment such as TearLab, Meibographers, InflammaDry testing, etc, can add such additional examinations to the procedure sequence.
Table 3: Clinical summary if the MGD staging use to guide treatment)
Treatment options
Despite general agreement among the recommendation of major clinical handbooks and studies such as the The International Workshop on Meibomian Gland Dysfunction, treatment of blepharitis and MGD varies greatly among eye care practitioners, from practice to practice and from country to country. Under-diagnosis is common and clinical follow-up is irregular.
Many forms of treatment have been proposed, studied and are used including artificial lubricants;59-64 topical lipid supplements;65-69 eyelid warming70-76 and mechanical eyelid hygiene;77-79 topical antibiotic agents such fusidic acid,80 metronidazole,81 fluoroquinolones82 and macrolides;83 systemic oral antibiotics including tetracycline and its derivatives;84 topical corticosteroids;85 calcineurin inhibitors and cyclosporine;86-88 and essential fatty acids supplementation.89
The International Workshop on Meibomian Gland Dysfunction developed a very useful treatment algorithm as depicted in table 4.
Table 4: Treatment algorithm
In relation to table 4, meibum quality is assessed in each of eight glands in the central third of the lower lid on a scale of 0 to 3 for each gland: 0 = clear; 1 = cloudy; 2 = cloudy with debris (granular); and 3 = thick like toothpaste (total score range from 0-24). Expressibility is assessed on a scale of 0 to 3 in the five glands in the lower and upper lid, according to number of glands expressible: 0 = all glands; 1 = three to four glands; 2 = one to two glands; and 3 = no glands. Staining scores are obtained by summing the scores of the exposed cornea and conjunctiva. Oxford staining score range from 1-15; DEWS staining score range from 0-33. (+) indicates the evidence base is limited to emerging. (+) indicates the treatment is supported by evidence at that stage in the disease.
Discussion
Clearly there is an opportunity for optometrists and in particular additional supply and independent prescribing optometrists to manage blepharitis, MGD and dry eye in all its many forms, for the most part, in primary care. This would ease the burden on our GP and secondary care colleagues by managing a group of diseases, which are largely non-sight-threatening. As a profession, we can therefore significantly impact a patient’s quality of vision and more importantly quality of life. Such patients can be time consuming and challenging, but positive patient outcomes can be hugely professionally rewarding.
The next article in this series will look at individual case management.
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