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Management of Meibomian Gland Disease and Ocular Surface Inflammation
Blepharitis is one of the more significant conditions seen by all ophthalmologists — comprehensive ophthalmologists, glaucoma and retina specialists, and cataract surgeons. Accordingly, more attention has been focused on blepharitis in the past few years, and it is now acknowledged that there are subsets of patients with blepharitis who warrant particular consideration.
First, the patient with blepharitis who is undergoing any type of eye surgery is at a higher risk for infection compared with a person without the condition.1 It is critical to diagnose and treat this condition prior to surgery. In some cases, delaying surgery until the inflammation is under control is recommended.
The second group of patients are those with chronic blepharitis, especially those with meibomian gland disease. These patients typically have visited multiple practices with chronic symptoms but without a specific diagnosis and without adequate attention paid to their condition. They are some of the most unhappy patients and, with their chronic disease, some will be found to have significant visual loss due to corneal damage.
Meibomian Gland Disease and Blepharitis
Blepharitis is classified as anterior (staphylococcal), seborrheic, or meibomian gland disease (Figure). Anterior blepharitis patients have loss of lashes, collarettes on the base of the lashes, and telangiectasia or erythema around the lashes. This condition is most commonly considered to be due to staphylococcal infection, and treatment includes lid hygiene with hot compresses and commercial lid scrubs to reduce the collarettes and the scurf at the base of the lashes. Antibiotic ointment to the lid margins is also implemented to treat this condition. Bacitracin and erythromycin are often used, and azithromycin became available more recently. Azithromycin provides a combined antibiotic and anti-inflammatory effect, contributing to effective management of the disease.2
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Figure. Blepharitis
Source: Edward J. Holland, MD and Eric D. Donnenfeld, MD |
Meibomian gland disease, also known as posterior lid margin disease, is commonly encountered by corneal specialists. These patients typically have been to several clinicians with persistent symptoms without receiving an accurate diagnosis. It is important to differentiate the patient with posterior lid margin disease from the dry eye and allergic eye disease patient, because the treatments are different.
Signs of posterior lid margin disease are inflammatory reaction at the posterior lid margin with erythema and telangiectasia around the gland opening, pouting of oil, and inspissation of the gland, which is evident as the thickened exudate when the gland is expressed. When the tear film is examined with fluorescein, a rapid tear break up time is apparent. As a result of this unstable tear film, these patients have evaporative dry eye.
Chronic meibomian gland disease can cause continual pain that severely affects the patient’s quality of life, even if findings are considered moderate. In addition, it can lead to chronic blepharoconjunctivitis, keratitis, scarring of the cornea, and neovascularization. This can result in a loss of vision that is difficult to treat with a corneal transplant because of recurrent inflammation in the graft.
Rosacea is also a common factor in posterior lid margin disease; approximately 20% of rosacea patients present with lid findings before facial changes are evident. Advanced rosacea causes scarring and neovascularization throughout the cornea. In addition to causing debilitating symptoms, profound visual loss can occur. Rosacea is becoming more common in younger patients, which may be related to diets that are high in fatty acids. If proper treatment of posterior lid margin disease is initiated promptly, adverse findings including vision loss may be reversed.
Although there can be a combination of findings in these patients, the primary process is due to the inflammation of the posterior lid margin. Simply addressing these patients with lid hygiene will not resolve their condition.
Keys to Proper Management of Meibomian
Gland Disease
Lid hygiene and warm compresses remain the cornerstone of therapy; the heat can melt the oils and the thickened secretions. It is important to assure that regimens are convenient and simple to enhance patient compliance. Commercially available lid scrubs are convenient, and using them in the morning and evening when patients are usually already at the sink performing their ablutions makes it adequately simple.
There is evidence that an overgrowth of bacteria and bacteria-produced lipases in meibomian gland disease assist with degrading fats into soaps, increasing the patient’s symptoms.3 Therefore, reducing these bacteria with antibiotics can contribute to disease management. Erythromycin or bacitracin can be used; however, azithromycin provides an important anti-inflammatory effect in addition to the antibacterial effect. Antibiotics can be rotated to reduce bacterial counts and the inflammation associated with lid margin disease.
Tetracyclines can be effective if used at the correct dose. Up to half of patients on antibiotic doses of doxycycline (100 mg BID) or tetracycline (250 mg QID) will have gastrointestinal (GI) side effects that may cause noncompliance with the regimen. In addition, ultraviolet light sensitivity at that dose can result in sunburn. However, these patients do not need such a high dose of tetracycline; in this situation, the drug is being used as an anti-lipid agent, not as an antibiotic therapy. In addition, they do not require an initial load at a higher dose. Accordingly, low-dose doxycycline will achieve the desired effect with fewer patients experiencing side effects compared to higher doses of doxycycline.4
A new topical antibiotic, azithromycin, has been found to be an effective treatment for meibomian gland disease. Azithromycin has been shown to have both an anti-infective as well as an anti-inflammatory mechanism in these patients.
Topical facial metronidazole is effective for rosacea on the face.5 However, if there are significant facial changes, the patient should be referred to a dermatologist because these changes can be very disfiguring. Some patients place the cream or ointment on their lids. It is well-tolerated and can have a therapeutic effect for some patients.
In addition, some patients will respond to nutritional supplements better than they do to doxycycline, and the reverse is true as well. Therefore, these approaches should be evaluated individually to determine which are optimal in these patients. Omega-3 fatty acids, which are found in flaxseed oil and fish oil, are nutritional supplements that have had a significant effect on some patients. Flaxseed oil thins the meibomian gland oils and thickens the oil layer, while fish oil suppresses inflammation. Accordingly, a combination of the two can work synergistically. These supplements are usually found in the dry eye section of the pharmacy.
Previously, safety concerns including development of cataracts, glaucoma, and steroid dependence precluded the use of steroids in chronic disease. However, if the inflammation is significant and causes daily pain, or if there are corneal findings, steroids are indicated. Topical loteprednol has been available more than 10 years, and it has been shown to be an effective steroid with a good safety profile. It has demonstrated efficacy in the conjunctiva, the cornea and the lids, with minimal adverse effects.6 IOP rise is less than 2% with loteprednol, which is less than that seen with other steroids. Accordingly, in patients who have practiced lid hygiene and taken antibiotics and nutritional supplements but who have persistent corneal findings or conjunctival inflammation and pain, corticosteroids are indicated. Loteprednol, with its efficacy and safety record, is a logical choice in this application.
In summary, meibomian gland disease can be associated with chronic pain that could compromise a patient’s quality of life. It is vital that this condition is correctly diagnosed and treated before it leads to complications such as visual loss. There are a number of treatment options for this condition. When choosing a treatment, it is important to weigh its benefit in reducing pain against the risk of side effects. It is also important to ensure treatment is administered at an appropriate dose.
References
- Mamalis N, Kearsley L, Brinton E. Postoperative endophthalmitis. Current Opinion in Ophthalmology. 2002 Feb;13(1):14-8.
- Ianaro A, Ialenti A, Maffia P, Sautebin L, Rombolà L, Carnuccio R, Iuvone T, D'Acquisto F, Di Rosa M. Anti-inflammatory activity of macrolide antibiotics. The Journal of Pharmacology and Experimental Therapeutics. 2000 Jan;292(1):156-63.
- Giamarellos-Bourboulis EJ. Macrolides beyond the conventional antimicrobials: a class of potent immunomodulators. International Journal of Antimicrobial Agents. 2008 Jan;31(1):12-20. Epub 2007 Nov 1.
- Yoo SE, Lee DC, Chang MH. The effect of low-dose doxycycline therapy in chronic meibomian gland dysfunction. Korean Journal of Ophthalmology. 2005 Dec;19(4):258-63.
- Gooderham M. Rosacea and its topical management. Skin Therapy Letter. 2009 Feb;14(2):1-3.
- Pavesio CE, Decory HH. Treatment of ocular inflammatory conditions with loteprednol etabonate. The British Journal of Ophthalmology. 2008 Apr;92(4):455-9. Epub 2008 Feb 1.