Treat blepharitis preoperatively for optimal results

Issue: September/October 2010

Surgeons recommend aggressive treatment until significant improvement in signs, symptoms is achieved.

Untreated blepharitis can cause an abnormal tear film, resulting in evaporative dry eye and possibly an increased risk of infection after cataract surgery. Aggressive treatment to improve the signs and symptoms of blepharitis before surgery prevents postoperative complications and results in a better outcome, a surgeon said.

“Patients with blepharitis have a higher concentration of bacteria in and around their eyes, which may be a source of infection following surgery,” William B. Trattler, MD, told Premier Surgeon. “Also, we want to ensure accurate measurements so that we can we can provide our patients with the optimal IOL selections. Patients with blepharitis have evaporative dry eye, which can result in inaccurate topography and keratometry readings. This can potentially throw off our IOL power selection. Additionally, for patients with significant astigmatism, inaccurate keratometry/topography can result in reduced accuracy with toric IOL axis alignment and/or limbal relaxing incisions.”

A poster presented at the annual American Society of Cataract and Refractive Surgery Symposium on Cataract, IOL and Refractive Surgery this year showed that 60% of patients scheduled for cataract surgery have blepharitis. Considering the prevalence in this patient population, Elizabeth A. Davis, MD, FACS, suggests a careful preoperative evaluation.

“Doctors should closely examine the lids for meibomian gland abnormalities, telangiectasia, and lid margin irregularities, the quality and quantity of the tear film, as well as the cornea and conjunctiva using vital dye staining,” Dr. Davis said.

Preoperative treatment

For patients with mild blepharitis, David R. Hardten, MD, typically starts with lid hygiene and instructs patients to use warm compresses, scrubs and over-the-counter shampoo to cleanse the eyelids. For more severe cases, topical azithromycin and oral antibiotics might also be helpful.

Editor’s note: Although they are not mentioned in the content of this article, other options are available for the treatment of blepharitis, including TobraDex (Alcon), punctual plugs, oral tetracyclines, omega-3 fatty acids, and various artificial tears. Premier Surgeon does not endorse or recommend any particular product or treatment.

“In some cases Restasis (Allergan) seems to work relatively well. Antibiotics and steroids are also helpful, but we worry about glaucoma from chronic steroids in the older population. Oral medications like doxycycline are oftentimes quite effective,” Dr. Hardten said. “A combination of some of these therapies works well; since there are a variety of different treatments, we basically try to tailor to the specific patient to control blepharitis in a way that doesn’t have many side effects or high toxicity, but is aggressive enough to have a good outcome.”

Parag A. Majmudar, MD, recommends AzaSite (Inspire Pharmaceuticals) preoperatively to sterilize the ocular surface and treat blepharitis and continues treatment after surgery to get the best result.

“In the setting of premium IOLs, the bar is raised much higher due to heightened patient expectations stemming from the self-pay nature of these cases. I believe AzaSite is a good preoperative treatment, and I use it at least 1 week prior to surgery. I also recommend maintenance therapy with warm compresses and lid scrubs, even though these typically suffer from compliance issues,” Dr. Majmudar said.

Differentiating ocular surface issues

Dr. Hardten said that some patients might confuse their ocular surface conditions with their cataract symptoms. In order to temper patient expectations, it is crucial to educate patients about which symptoms are a result of their cataract and which are a result of dry eye or blepharitis.

“If you take a patient who thinks they only have a problem with cataracts and after surgery they’re still left with uncomfortable and irritated eyes, they’re going to be unhappy because they might have been blaming those symptoms on their cataract. It’s important to figure out what’s going on with the blepharitis and then address that beforehand so they can separate those issues in their mind,” Dr. Hardten said.

Aggressive treatment

Patients who have “new” blepharitis or dry eye after cataract surgery may be blepharitis patients whom doctors did not identify before surgery, Dr. Hardten said. In order to prevent postoperative complications, aggressively diagnose and treat patients preoperatively from first suspicion.

“The biggest problem is a tear film that is not as stable as it could be before surgery. Postoperative dry eye does not start because of surgery; the patient has an underlying problem that was not diagnosed or managed preoperatively that tends to get worse after surgery,” Dr. Hardten said. “Doctors know if they’re being aggressive enough in their treatment if IOL patients are happy with the quality of their vision.” — by Stephanie Vasta

Elizabeth A. Davis, MD, FACS, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. South, Bloomington MN 55431; 952-567-6067; fax: 952-885-9942; e-mail: eadavis@mneye.com.

David R. Hardten, MD, can be reached at Minnesota Eye Consultants, 710 E. 24th St., Suite 100, Minneapolis, MN 55404; 612-813-3600; fax: 612-813-3658; e-mail: drhardten@mneye.com.

Parag A. Majmudar, MD, can be reached at Chicago Cornea Consultants, 1725 West Harrison St., Suite 928, Chicago, IL 60612; 312-942-5300; pamajmudar@chicagocornea.com.

William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@gmail.com.

References:

Groden LR, Murphy B, Rodnite J, Genvert GI. Lid flora in blepharitis. Cornea. 1991;10(1):50-53.

Luchs J, Buznego C, Trattler W. Prevalence of blepharitis in patients scheduled for routine cataract surgery. Poster presented at: The ASCRS Symposium on Cataract, IOL and Refractive Surgery; April 11, 2010; Boston, MA.