Blepharitis remains a common and important ophthalmologic presentation

ByEric D. Donnenfeld, MD

It is predicted that as many as 70 to 80 million Americans have blepharitis of some type, and the sequelae associated with this condition can be damaging.

—Eric D. Donnenfeld, MD

Blepharitis is an extremely common presentation in ophthalmology offices and is arguably one of the most important problems currently addressed. It is predicted that as many as 70 to 80 million Americans have blepharitis of some type, and the sequelae associated with this condition can be damaging. These can include chalazia, dry eyes, punctate keratitis, pannus, phlyctenules, corneal ulceration and endophthalmitis. This article discusses the pathology and etiology of blepharitis and treatment options for this extremely common and potentially severe problem.

Anterior blepharitis

Posterior blepharitis is more common, but anterior blepharitis is a significant problem as well. Anterior blepharitis is most commonly caused by Staphylococcus infections. It is characterized by pustule formation, loss of lashes and erythema. Symptoms of staphylococcal immune disease such as phlyctenule and pannus will also occur.

Recently, the Blepharitis Eye Treatment Advisory panel (BETA) recommended a series of treatments for anterior blepharitis. The first step is lid hygiene; this includes the use of a commercial scrub such as SteriLid (Advanced Vision Research) or OcuSoft Lid Scrub or Eye-Scrub (Novartis) twice a day for 2 days and thereafter once a day. Lid hyperthermia is also crucial to the treatment. This can be achieved by heating a potato or an egg, or just a wet cloth, and holding it to the patient’s eye for 5 minutes once every day.

Finally, topical antibiotics such as azithromycin drops once a day or bacitracin ointment twice a day are used to treat the infection. The DAM method should be used for antibiotic administration: Drop And Massage. After the drop is put in, the patient should massage the medication into the affected eyelid.

Figure 1: Eyelid penetration of azithromycin

Meibomian gland disease

Posterior blepharitis is also known as meibomian gland disease. In this condition, normal meibomian gland secretions are converted from unsaturated lipids to saturated fats; these inspissate the gland. This occurs because Staphylococcus bacteria secrete lipases that break down normal lipids into the soaps and fatty acids (Figure 1).

Symptoms of posterior blepharitis include burning and foreign body sensations that are usually worse in the morning. Patients experience filmy vision with a tear film that contains soaps and fatty acids, and will have dilated meibomian gland orifices plugged with a toothpaste-like material. Chalazia and thickened lid margins also occur.

Supplements that contain fish oils and flaxseed oil can be an effective component of blepharitis treatment.

—Eric D. Donnenfeld, MD

The BETA panel recommendations are identical for posterior and anterior blepharitis: lid hygiene with a commercial scrub, lid hyperthermia, and then topical antibiotic. The antibiotic should be stopped after 1 month, but it can be restarted a month later if the patient has recurrent inflammation. This can be continued every other month as needed.

Further recommendations for posterior blepharitis include nutritional supplements as part of primary therapy. Supplements that contain fish oils and flaxseed oil can be an effective component of blepharitis treatment. If this is still insufficient to induce a response, oral doxycycline 50 mg/day can be used, as can topical corticosteroids or topical cyclosporine.

Importance of antibiotic penetration

Even though anterior and posterior blepharitis are different conditions, it is clear that lid bacteria play a critical role in both. Thus, the antibiotic portion of the treatment is crucial, and there are concerns with some antibiotic therapies. Topical antibiotic drops applied to the tear film have limited contact with the lid margin and very little penetration into the lid tissue. Also, antibiotic ointments not only blur vision, but also do not penetrate the tissue well.

Azithromycin is a broad-spectrum antibiotic and is highly penetrative into the relevant tissues. Topical dosing results in very high concentrations in the tear film, the conjunctiva and the lid margin. The use of the DuraSite bioadhesive stabilizes the azithromycin and increases its bioavailability. When the drop is administered, it adheres to the lid margin and penetrates the tissues. Azithromycin also has been shown to have anti-inflammatory effects without the side effects of a corticosteroid.

Studies in a rabbit model have shown the high levels of tissue penetration with azithromycin (Table 1). Lid margins have been found to have a maximum concentration of 50 µg/g after a single administration. Controlled clinical trials in humans will give conclusive results, but to this point the use of azithromycin for blepharitis has been extremely successful. An open label study has shown marked improvement of lid margin disease with topical azithromycin and a masked, controlled study is under way. Keeping this and the full treatment algorithm in mind for both anterior and posterior blepharitis will help manage these extremely common and potentially dangerous conditions.

Table 1: Pharmacokinetic measures for 0.5% ISV-401: Single instillation in rabbits