The last article in this series (Optician 02.12.16) offered an overview of blepharitis and meibomian gland dysfunction (MGD) and their management. After a brief revision of the main points made then, this article will describe atypical case where this knowledge is applied resulting in a successful outcome for the patient.

Table 1: Classification of MGD

As discussed previously, 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 deliver states. High delivery hypersecretory MGD is characterized by the release of a large volume of lipid at the lid margin that becomes visible on application onto the tarsus during examination.1

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 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 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;2-7 topical lipid supplements;8-12 eyelid warming13-19 and mechanical eyelid hygiene;20-22 topical antibiotic agents such fusidic acid,23 metronidazole,24 fluoroquinolones25 and macrolides;26 systemic oral antibiotics including tetracycline and its derivatives;27 topical corticosteroids;28 calcineurin inhibitors and cyclosporine;29-31 and essential fatty acids supplementation.32

The International Workshop on Meibomian Gland Dysfunction developed a very useful treatment algorithm as depicted in table 4.

Table 4: Treatment algorithm

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 to 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 to 15; DEWS staining score range from 0 to 33. (±) indicates the evidence base is limited or emerging. (+) indicates the treatment is supported by evidence at that stage in the disease.

Case history

This case history aims to showcase co-morbidity of lid margin disease, how it can be evaluated and treated.

History and symptoms

An 88-year-old gentleman attended at the request of his GP complaining of red and irritable eyelids. Symptoms included;

  • Intermittent ocular discomfort.
  • Foreign body sensation.
  • Soreness, burning and itching.
  • Mild photophobia.
  • Mild intermittent blurred vision.
  • Stringy mucous discharge bilaterally.
  • A watery left eye.

He also reported a small growth on the upper lid of the left eye of unknown onset. He had been using baby shampoo to bathe his eyelids twice a day and hypromellose eye drops for around 12 months with no improvement in his symptoms.

Past ocular health

He was under HES care (macular clinic) at the time of presentation and being treated for exudative age-related macular degeneration in his left eye. Treatment had commenced in 2013 and he had undergone 13 Lucentis injections in left eye only to date.

Family ocular health

Both parents were myopic and had age-related cataracts.

General health

  • In good health. No known allergies.
  • Mild systemic hypertension and hypercholesterolaemia, both monitored regularly by GP.
  • Non-smoker.
  • Facial acne rosacea (receiving no treatment for this).

Medications and supplements

  • Ocuvite Complete (supplement for his AMD).
  • Simvastatin (for his cholesterol).
  • Ramapril (for his hypertension).

Vision, refraction and visual acuity

Vision | Refractive error | Visual acuity | Add | Near visual acuity

R: 6.7.5-1 | +0.25 / +0.25 x 120 | 6/7.5+2 | +2.50 | N5

L: 6/12-1 | -0.25 / +1.50 X 50 | 6/7.5-2 | +2.50 | N6

Examinations

Pupil reactions: Normal

Oculomotor balance: Small near exophoria. Well controlled.

Visual field analysis (24-2 Threshold algorithm):

R: Abnormal. Inferior arcuate scotoma

L: Abnormal. Minor inferior arcuate scotoma

IOP: R: 10mmHg; L: 11mmHg

(Using Goldmann applanation tonometry 11.15am)

Central corneal thickness:

R: 482µm L: 486µm

Posterior pole:

Right eye:

Macula:

Small number of soft drusen

Left eye:

Sub-foveal disruption

Optic nerve head:

Right eye

Large C/D ratio 0.8

thin superior neuroretinal rim (NRR) and RNFL

Left eye

Large C/D ratio 0.7

Slightly thin superior NRR and RFNL

Speed questionnaire score:

20/28 – severe symptoms.

Initial differential diagnosis:

  • Aqueous deficient dry eye.
  • Evaporative dry eye.
  • Neuropathic dry eye.
  • Demodex blepharitis due to presence of rosacea.

Clinical assessment:

Slit-lamp findings are summarised in table 5.

Table 5: Slit Lamp Examination

Figure 1: Anterior image of right eye lower lid: Reveals inflammation of lid margin, lash misalignment, trichiasis and madarosis. Conjunctival hyperaemia and lash debris also visible

Anterior eye examination: right eye

Figure 1 shows the anterior eye appearance of the right eye lower lid and shows;

  • Inflammation of lid margin
  • Lash misalignment
  • Trichiasis
  • Madarosis.
  • Conjunctival hyperaemia
  • Lash debris

Figure 2: Anterior image of right eye upper lid: Reveals lash misalignment and significant scales and cylindrical dandruff on lid margin

Figure 2 shows the anterior eye appearance of the right eye upper lid and shows;

  • Lash misalignment
  • Significant scales and cylindrical dandruff on lid margin

Anterior eye examination: left eye

Figure 3: Anterior eye image upper lid left eye: Shows lash debris and lesion in keeping with a cutaneous horn

Figure 3 shows the anterior eye appearance of the left eye upper lid and shows;

  • Lash debris
  • Suspected cutaneous horn

Figure 4: Anterior eye image lower lid left eye: Reveals ectropion of lower li

Figure 4 shows the anterior eye appearance of the left eye lower lid and shows;

  • Ectropion

Tear evaporation measurement

Figure 5 shows the non-invasive automated tear break up time taken using an Oculus K5. Results reveal a slightly reduced tear break up time (TBUT) in the right eye of 7.78secs and a significantly reduced tear break up time in left eye of 1.78secs.

Figure 5: Non-invasive TBUT results with an Oculus K5

Meibography

Meibography of the left eye (figure 6) revealed a moderate shortening of upper and lower meibomian glands and a mild shortening of upper and lower meibomian glands for the right eye (figure 7).

Figure 6: Meibography of left eye

Figure 7: Meibography of right eye

Diagnosis

  • Bilateral mixed blepharitis.
    • The lid margin hyperaemia and oedema, crusting of anterior lid margin, misdirection of lashes, madarosis and trichiasis, conjunctival hyperaemia and inferior punctuate staining suggest anterior marginal blepharitis as a result of staphylococcal involvement and possibly demodex involvement (see figures 1 to 4).
    • The shortening and atrophy of the meibomian glands and poor quality and consistency of expressed meibum suggest meibomian gland dysfunction (posterior blepharitis) (see figures 6 and 7).
  • Bilateral evaporative dry eye with a mild aqueous deficient component is suggested by the poor tear evaporation rates in both eyes. The slightly reduced tear volume measurements in the right eye and the formation of mild mucous plaques suggest abnormal tear mucous production (see figure 5).
  • Ectropion in left eye only explains poor tear drainage and resultant epiphora (see figure 3).
  • Subcutaneous horn in left eye (see figures 3 and 4).
  • Corneal mucous plaque suggestive of mild filamentary keratitis.

Figure 8: Lid treatment using the BlephEx

Management

In practice treatments

1 Trichiasis (right eye) – In-house epilation of affected eye lashes.

2 Anterior blepharitis – In house cleaning via microblepharoexfoliation using BlephEx (See figure 8 and figure 9 for before and after images).

a Disposable MGDRx Eye Bag Instant used to warm the anterior surfaces for 10 minutes.

b One drop of single use (preservative-free) Minims proxymetacaine: eye drops, 0.5% proxymetacaine hydrochloride instilled in each eye to minimise blink reflex.

c Ocusoft Foam applied to the closed eyelids to act as a foaming, cleaning agent.

d BlephEx cleaning wand used to remove debris from eyelashes and lid margin.

3 Posterior blepharitis – In house treatment using heat and forceps to express meibomian glands utilised. The eye was irrigated with preservative free saline afterwards to reduce inflammation on the ocular surface.

Figure 9: Anterior image right eye: Before and After BlephEx cleaning of eye lashes and eye lids

At home treatments and advice

1 Mixed blepharitis.

a Heat application via an MGDRx Eye Bag, 10 minutes, twice per day.

b Lid massage to express melted meibum immediately after heat application.

c Lid hygiene via Cliradex pads twice per day immediately after heat and expression for 60 days to attempt to eradicate the demodex.

d Topical chloramphenicol 1.0% ointment twice per day for two weeks.

e Use of oral antibiotic doxycycline 50mg twice per day for three months.

f Omega Eye omega III supplements, four capsules a day for six months.

2 Evaporative Dry Eye (leave 10 minutes between eye drops).

a Emustil 7% Soybean oil and 3% Natural Phospholipids eye drops. One drop both eyes, four times per day. Used to replace lipids in tear film and improve tear evaporation rate.

b Ilube eye drops, 5% acetylcysteine, 0.35% hypromellose. One drop both eyes, four times per day used to treat mucous plaques.

c Vit A-POS: eye ointment, retinol palminate 250 units/g, white soft paraffin, light liquid paraffin, wool fat. Use before bed.

3 Cutaneous horn & ectropion.

a Referral to oculoplastics. Histopathologic examination of the base of the cutaneous horn lesion is necessary to establish the definitive diagnosis. Request opinion on left eye ectropion.

Figure 10: Improvement in non-invasive treat break-up time with treatment. Right eye

Written information and advice

The patient was given a written treatment plan to improve compliance. A written report was sent to the patient GP.

Figure 11: Improvement in non-invasive treat break-up time with treatment. Left eye

Follow-up examinations

The patient has been followed closely over the past two years to ensure good compliance to treatments, proper management and improvement in patient’s symptoms and clinical signs, all to ensure no escalation of treatment required.

1 Significant improvement in the patients SPEED index scoring (baseline score 20/28, current score 8/28) and positive anecdotal feedback from the patient both suggest significant improvements in the patient’s symptoms and therefore quality of life.

2 Significant improvement in tear evaporation rates measured (see figures 10 and 11).

3 Vast improvements in lid margin oedema, inflammation, hyperaemia achieved and cleanliness achieved.

4 Resolution of inferior corneal staining and corneal mucous plaques achieved.

5 Cutaneous horn deemed benign and spontaneously resolved around 12 months after diagnosis.

6 Monitoring of ectropion on-going, however thus far no surgical intervention required.

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 GPs 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 by hugely professionally rewarding.

Craig McArthur is involved in a dedicated anterior eye clinic service at Peter Ivins Eyecare practice in Glasgow.

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