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Children with blepharitis often require specialized care
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As a specialist in cornea and external disease, I will focus my comments on the topic of blepharitis in the pediatric age group. Our children in America are currently growing up in what many experts call an “obesogenic environment.” In the U.S., one in three children under the age of 11 years is overweight and one in six has a BMI high enough to be considered obese. This obesogenic environment includes a saturated fatty acid and refined sugar rich diet with too many calories per day, reduced outdoor activity and exercise, and a lifestyle that includes hours of near work, computer games and television. Besides obesity, this lifestyle change is contributing to an epidemic of myopia, diabetes, hypertension and, yes, even meibomian gland dysfunction, blepharitis, and the associated hordeoli and chalazia.
The ideal treatment would include diet modification, increased exercise and resolution of obesity, but management of childhood obesity is complex and outside the purvey of most ophthalmologists. Because nearly all children in the U.S. are under the care of a pediatrician or family physician, most of us will delegate this potentially life-saving treatment to them. We can, of course, give encouragement.
Treatment of blepharitis has been discussed in my commentaries before and is well discussed in the accompanying cover story. I will add just a few thoughts.
Avenova (NovaBay) sprayed on the eye and lids at least twice daily is fairly easy to initiate in children, is safe and can be effective. Omega-3 supplements are also helpful. Most studies show eating breakfast is important in the treatment of obesity, and flaxseed added to breakfast cereal can serve to improve the omega-3 to omega-6 ratio. This is sometimes easier than capsules, liquid omega-3 supplements or gummies. Heat can still be helpful, and most children will tolerate a Bruder mask. Azithromycin 1% topical in difficult cases systemically can be safe and effective. I personally do not use tetracycline compounds in children.
Many studies confirm that the most effective treatment for putting significant symptomatic blepharitis into remission is a topical steroid or steroid/antibiotic combination. Fortunately most patients respond in 1 to 2 weeks, and the steroids can be discontinued with transition to safer long-term maintenance therapy. Remissions may require a repeat course of topical steroids. While controversial, in desperate cases with significant corneal vascularization and recurrent infiltrates, long-term use of non-preserved loteprednol ointment can be effective. Careful informed consent with the parents regarding the risks and frequent follow-up to screen for IOP elevation are required. Topical Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or the recently available Xiidra (lifitegrast ophthalmic solution 5%, Shire) is off label but often helpful. Topical drops can be used in a drop and massage approach in which they are rubbed into the lid margins after application with a clean fingertip. LipiFlow (TearScience) works well for many children and is usually well tolerated past the age of 6 years. It takes some form of anesthesia to do manual lid expression or excision and drainage of significant hordeoli or chalazia.
The child with significant obesity, blepharitis, especially if associated with madarosis, floppy lid syndrome, phlyctenules, corneal infiltrates, or recurrent hordeolum and chalazion is extremely difficult to manage for most ophthalmologists. Referral to a setting in which multidisciplinary care is available, including a pediatric ophthalmologist, corneal specialist and pediatricians expert in the management of obesity, is a prudent approach in the more difficult cases.