1. Lash follicles
Not long after the entire lid margin is covered with biofilm, the lash follicle becomes the first structure to be affected by excess bacterial biofilms and associated toxins because of the follicle’s easy access and small size. When the biofilm progresses into the lash follicles, folliculitis ensues. This is a subtle clinical finding that can be easily missed on cursory anterior segment examination if not appropriately assessed.
The lash follicle manifests a volcano sign in which the skin surrounding the lash follicle is elevated with edema (Figures 2A and 2B). Many times pallor is noted as well, especially in darker-skinned patients. This is due to an “activated” toxin-producing bacterial biofilm that is present within the follicle.
As the biofilm thickens around the base of the lash, small pieces begin pull loose from the main layer due to the growing lash. The main layer of biofilm extends back across the entire lid margin, but it is nearly invisible due to its translucence and tight adherence to the lid margin.
Once the slightest amount of air gets under the biofilm, however, it becomes easily visible. This is typically when ODs are able to clinically identify blepharitis, but the process starts much sooner than visible biofilm at the base of the lashes.
It is critical to closely examine the lid margin for early volcano signs at the base of the lashes. Treatment at this stage will prevent further damage and protect the meibomian glands.
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