5Anterior blepharitis Anterior blepharitis is characterized by inflammation at the base of the eyelashes . Patients with anterior blepharitis, compared to those with posterior blepharitis, are more likely to be female and younger ** McCulley, JP, Dougherty, JM, Deneau, DG. Classification of chronic blepharitis. Ophthalmology 1982; 89:1173.
6Two variants of anterior blepharitis are identified: staphylococcal and seborrheic. In staphylococcal anterior blepharitis, colonization of the eyelids by staphylococci leads to formation of fibrinous scales and crust around the eyelashes.The seborrheic variant is characterized by dandruff-like skin changes around the base of the eyelids, resulting in greasy scales around the eyelashes.
7PATHOPHYSIOLOGYThe pathophysiology of blepharitis is not completely understood. A role for lid-colonizing staphylococcal bacteria was first noted in Several mechanisms by which staphylococci may alter meibomian gland secretion and cause blepharitis are supported by many studies .Direct infection of the lidsEvoke reaction to staphylococcal exotoxinProvoke allergic response to staphylococcal antigens .It is likely that a combination of these is responsible for the clinical manifestations of staphylococcal blepharitis.
8CLINICAL PRESENTATION symptomsburning , grittiness and mild photophobia with remission and exacerbation is characteristic .Symptoms are usually worse in the morning , although in patients with dry eye they may increase during the day .
9note : because of poor correlation between the severity of symtpmos and clinical signs it can be difficult to objectivley assess the benefit of treatment .
10signs A. Staphylococcal blepharitis Hard scales and crusing mainly located around the bases of the lashes esp. collorettechronic conjunctival hyperemia with mild papillary conjunctivitis .
11Staphylococcal blepharitis Chronic irritation worse in morningHyperaemia and telangiectasia of anterior lid marginScales around base of lashes(collarettes)Scarring and hypertrophy if longstanding
12Cont. Signs of Staphylococcal blepharitis scarring and notching (tylosis) of the lid margin , trichiasis (misdirected eyelashes), madarosis (loss of lashes) or poliosis (loss of pigmentation of lashes) in sever long standing cases
14Cont. Signs of Staphylococcal blepharitis secondary changes include stye formation , marginal keratitis and occasionally phlyctenulosis (Corneal nodulesthat developed near the limbus and then spread onto the cornea, carrying behind them a leash of vessels) .associated with tear film instability and dry eye .
15Signs of seborrheic blepharitis Hyperemic and greasy anterior lid margin with sticking together of lashesthe scales are mainly scruf , and located any where on the lid margin and lashes .
16Seborrhoeic blepharitis Shiny anterior lid marginGreasy scalesHyperaemia of lid marginLashes stuck together
17DIAGNOSISThe diagnosis of blepharitis is clinical, based on the patient's history and physical examination findings. There are no confirmatory diagnostic tests or laboratory investigations.The history should include questions about symptom duration, smoking, allergens, contact lenses, and use of retinoids which may provoke or exacerbate symptoms. A history of acne, rosacea, or eczema should be evaluated .
18External examination The patient's facial and scalp skin should be examined for findings typical of seborrheic dermatitis (itching and flaking scalp or facial skin) or acne rosacea (facial flushing, broken or swollen blood vessels on cheeks and nose, and a red or swollen nose).
19TretmentThere is little evidence to support any particular protocol for anterior blepharitis .Patient should be advised that lifelong treatment may be necessary and that permenent cure is unlikely . But control of symptoms is usually possible .
20Cont. treatment Lid hygiene warm compresses applied for several minutes to soften crusts at the bases of the lashes .Lid cleaning to mechanically remove crusts involve scrubbing of the lid margins once or twice daily with a cotton dipped in a dilute solution of baby shampoo or NaHCO3 .Commercially produced soap/alcohol impregnated pads for lids scrubs are available .
21Cont. treatment 2.Antibiotics *Topical *Oral sodium fucidic acid , bicarbonate or chlormaphinicol : used to treat acute folliculitits but is of limited value for long standing cases*OralAzithromycin (500mg daily for 3 days ) may be helpful to control ulcerative lid margin disease .
22Cont. treatment3. Weak topical steroids Such as flurometholone 0.1 % QID for 1 week is usful for patients with sever papillary conjunctivitis , marginal keratitis and phlyctenulosis . 4. Tear substitutes Required for associted tear film instability and dryness
23Posterior blepharitis Posterior blepharitis, the more common condition, is characterized by inflammation of the inner portion of the eyelid, at the level of the meibomian glands . It is often described as meibomian gland dysfunction.
24PathophysiologyMG are modified sebaceous glands located within the tarsal plates . These holocrine glands are responsible for secretion of the oily layer of the tear film This oily layer prevents tear evaporation and reduces the surface tension of the tear layer, thereby facilitating the spread of tears over the ocular surface . It is critical for normal ocular surface lubrication.Posterior blepharitis is caused by meibomian gland dysfunction and alteration in miebomian gland secretion .
25Bacterial lipase may result in the formation of free fatty acid Bacterial lipase may result in the formation of free fatty acid . This increase in the melting point of meibum preventing its expression from the glands, contributing to occular surface irritation and possibly enabling growth of S. aureus .Loss of the tear film phospholipid that act as a surfactant result in increased tear evaporation and unstable tear film .
26DIAGNOSISthere is poor correlation between severity of symptoms and the clinical signs .symptoms :Similar to anterior blepharitisSigns :
27Signs* Excessive and abnormal meibomian gland secretion which may manifest as capping of meibomian gland orifices with oil globule .
28Cont. signspouting, recession or pulgging of the meibomian gland orifices with hyperemia and telangictasis of the posterior lid marginInflamed and blockedmeibomian gland orificesPlugging of meibomian gland orifices
29Cont. signspressure on the lid margin result in expression of meibomian fliud that may be turbid or appear like tooth paste . In sever cases the secretions become so inspissated that expression is impossible .Toothpaste-like plaquesfrom meibomian glands
30Cont. signsthe tear film is oily and foamy and froth may accumelate on the lid margin or inner canthi .Oily and foamy tear filmFoam in meibomian seborreha
31ASSOCIATED OCULAR CONDITIONS ChalazionWhich maybe multiple and recurrent , is common particularly in patient with posterior blepharitis .Tear film instability and dry eyeIs found in 30-50% of patients probably as aresult of imbalance between the aques and lipid components of the tear film allowing evaporation . Tear film break up tim eis typically reduced .Epithelial basement membrane defects
32ASSOCIATED OCULAR CONDITIONS Cont. Cutaneousacne rosacea is often ass. With MGDSeborrhoeic dermatitis is present >90% of patients with seborrhoeic blepharitisAcne vulgaris : due to treatment with isoretinoinContact lens intoleranceLong-term contact lens wear is associated with posterior lid margin disease .
33posterior blepharitis is often found in association with skin conditions such as rosacea and seborrheic dermatitis .Rosacea is associated with plugging and hypertrophy of the sebaceous glands. Since the meibomian glands are modified sebaceous glands, rosacea may lead directly to meibomian dysfunction .Seborrheic dermatitis is also associated with inflammation of the meibomian glands.
35treatmentIts very important to tell the patient that cure is unlikely although remession may be achived .1.Lid hygineAs in anterior blepharitis with emphasis on messaging the lid to express acumilated meibum, the messaging is toward the lid margin edge to “milk” meibum .
362. Systemic tetracycline Are the mainstay of treatment .It is used mainly to block staphylococcal lipase production .It is particularly idicated in patients with recurrent phlyctenulosis and margina keratitis .Note , tetracycline sohuld not be used inChildren less than 12 yrsPregnant womenLactating womendue to “ staining of bone and teeth & dental hypoplasia
37Types of tetracycline : Oxytetracycline : 250mg BD for 6-12 wksDoxycycline : 100mg BD for1wk then daily for wksMinocycline : 100mg daily for 6-12 wksErythromycine : 250 mg daily or BD “ may be used in children “
38Cont. treatment3. Topical glucocorticoids There may be a role for topical glucocorticoid use in the short term treatment of acute blepharitis exacerbations. Patients should generally be evaluated by an ophthalmologist prior to its initiation “ to adjust benefit VS S/E “
394. Topical cyclosporineTopical cyclosporine 0.05 percent eye drops were approved for the treatment of dry eyes by the US FDA inSeveral studies have investigated off-label use of these drops in the treatment of blepharitis with promising results. Topical cyclosporine use has led to reduction in symptoms , and improved clinical findings in patients with posterior blepharitis [1,2].Its has a high cost , so it should be reserved to refractory cases only .(1) Rubin, M, Rao, SN. Efficacy of topical cyclosporin 0.05% in the treatment of posterior blepharitis. J Ocul Pharmacol Ther 2006; 22:47.(2) Perry, HD, Doshi-Carnevale, S, Donnenfeld, ED, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea 2006; 25:171.
40Future treatmentSeveral topical medications are under evaluation as treatment for blepharitis. Topical metronidazole is a potential substitute for the use of systemic antibiotics, especially in cases of blepharitis related to rosacea *Cohen, EJ. Cornea and external disease in the new millennium. Arch Ophthalmol 2000; 118:979.
41Future treatmentTopical tacrolimus ointment has been used to treat severe refractory blepharitis with good results (1)Development of effective tear lipid substitutes may palliate the symptoms of blepharitis (2)1 . Joseph, MA, Kaufman, HE, Insler, M. Topical tacrolimus ointment for treatment of refractory anterior segment inflammatory disorders. Cornea 2005; 24:417.2. McCulley, JP, Shine, WE. Changing concepts in the diagnosis and management of blepharitis. Cornea 2000; 19:650.
42Special cases Allergic blepharitis — Allergic blepharitis is an acute inflammatory reaction of the skin of the eyelids, usually occurring as a reaction to a contact irritant . The skin of the eyelids will be typically very red, swollen and itchy. Treatment is aimed at identifying and eliminating use of the offending agent.
43Demodex folliculorum — Demodex is a parasite that commonly inhabits the eyelash follicle in patients with and without blepharitis . Although this parasite can cause some changes in the eyelash follicles esp. sleave scales , but still there is no evidence that it is directly associated with blepharitisPicture demonstrating thinning of eyelids secondary to corticosteroid use. Note sleeves and scurf
44Sebacous gland carcinoma What is your diagnosis ?Sebacous gland carcinoma
45— Blepharitis is nearly always bilateral — Blepharitis is nearly always bilateral A malignant tumor of the lid skin (ie, sebaceous cell carcinoma) should be suspected in a patient with persistent unilateral eyelid inflammationOther symptoms of malignancy include failure to respond to treatment, a nodular mass, ulceration, extensive scarring, or conjunctival nodules surrounded by inflammation