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Type and cause of the condition are important to discuss during the examination
Do I have pink eye?” How many times have ODs heard that question from their patients? The answer is usually, “Yes, you do have a pink eye and that’s why you came to see us today.”
The pink eye question gives me an opportunity to explain to the patient that not all eyes become “pink” for the same reason. I tick off the extensive list of differentials of conjunctivitis.
The patient generally exhibits amazement at the depth and breadth of causes of “pink eye” and is pleased that she has come to a specialist to tease out the preferred treatment plan rather than experimenting in self-prescribed folk, over-the-counter (OTC), or internet-search remedies. After all, does not witch hazel cure everything, (said tongue in cheek).
As I practice, the same educational segue sparks when blepharitis is the diagnosis at hand (often associated with conjunctivitis, keratitis, or both). Types of blepharitis include but are not limited to:
Herpetic blepharitis (simplex or zoster)
Meibomian gland dysfunction (MGD)
Eyelash mites or lice (demodex/pediculus)
Of course, there may be overlap of some of these conditions as one may initiate or potentiate the other. Treatment strategies for blepharitis vary and target the root cause of eyelid infection/inflammation.
Causes of blepharitis differ depending on whether it is an acute or chronic process, and in the case of chronic, the location of the problem.
Acute blepharitis may be ulcerative or non-ulcerative. An infection causes ulcerative blepharitis. This is usually bacterial and most commonly staphylococcal. A viral etiology such as infection with herpes simplex and varicella zoster is also possible. Non-ulcerative is usually an allergic reaction such as atopic or seasonal.
Its location best classifies the chronic form of blepharitis. In anterior blepharitis, an infection, usually staphylococcal, or seborrheic disease process is involved. Also, blepharitis may be associated with rosacea. Meibomian gland dysfunction (MGD) causes posterior blepharitis. Commonly, this is associated with acne rosacea, and hormonal causes are suspect.
Demodex mites may cause both anterior (Demodex folliculorum) and posterior (Demodex brevis) blepharitis. Their role is not well established because asymptomatic individuals have also been found to harbor the mites at approximately the same prevalence.1
Assessing eyelid health is important because there is a close association with blepharitis and MGD in ocular surface disease.
Rynerson and Perry coined the new term of dry eye blepharitis syndrome (DEBS).2 A biofilm structure is a target for colonizing bacteria. The invasion initiates quorum-sensing gene activation, subsequently producing inflammatory “virulence factors,” including super-antigens, which persist for a lifetime.
These factors cause follicular inflammation, infected eyelash bases, MGD, aqueous deficiency (lacrimalitis), with lid damage and destruction sustained in the long term. In more advanced stages, eyelid destruction can be accompanied by an ectropion or entropion or may cause an eyelid to become floppy.3
Eyelid hygiene and elimination of triggers that exacerbate symptoms remains the foundation of most treatment regimens for blepharitis.4
In-office microblepharoexfoliation of the lid margin (BlephEx, Rysurg) removes cellular/makeup/other debris from the eyelid margins, promoting a more normal lid/eyelash environment.
Patient maintenance of the eyelid margin includes daily lid margin cleansing (with a doctor recommended eyelid hygiene product, makeup remover, micellular water, hypochlorous acid solution, tea tree oil-containing product).
Hygiene products include wipes or foams or daily at-home lid/eyelash cleaning/debridement with a NuLids motorized unit (NuSight Medical) or the novel, multi-use iLidClean wand (Optego Vision). Similarly, Bruder has introduced a pre-surgical prep kit targeted to improve pre- and post-surgical eye health by eyelid hygiene.
Of note, Tarsus Pharmaceuticals will initiate a Phase 2b/3 trial in the United States of its lead product TP-03 for demodex. It is estimated 20 million Americans suffer from blepharitis, and approximately 45 percent of them have clinical signs of demodex.5
Be a hero
I encourage anyone interested in better lid margin hygiene and treating blepharitis to read my favorite lid margin article of all time, How to promote and preserve eyelid health by Jose Benitez-del-Castillo, my eyelid margin guru.6
Be a lid margin hygiene hero.
1. Eberhardt M, Rammohan G. Blepharitis. StatPearls. Available at: https://pubmed.ncbi.nlm.nih.gov/29083763/. Accessed 12/30/20.
2. Rynerson JM, Perry HD. DEBS—a unification theory for dry eye and blepharitis. Clin Ophthalmol. 2016 Dec 9;10:2455-2467.
3. Verjee MA, Brissette AR, Starr CE. Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians. Ophthalmol Ther. 2020 Dec;9(4):877-888.
4. Duncan K, Jeng BH. Medical management of blepharitis. Curr Opin Ophthalmol. 2015 Jul;26(4):289-94.
5. Tarsus Pharmaceuticals. Tarsus Pharmaceuticals Raises $60 Million in Series B Financing. Available at: https://www.prnewswire.com/news-releases/tarsus-pharmaceuticals-raises-60-million-in-series-b-financing-300983254.html. Accessed 12/30/20.
6. Benitez-del-Castillo J. How to promote and preserve eyelid health. Clin Ophthalmol. 2012;6:1689-98.