How to fix dry eye blepharitis syndrome: Remove biofilm early and often
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We published a peer-reviewed article, “A unification theory for dry eye and blepharitis,” in Clinical Ophthalmology in 2016.
The article explained how biofilm along the margin and within the structures of the eyelid allows bacteria to produce toxins that elicit an inflammatory response that never abates.
Source: Hank D. Perry, MD, and James Rynerson, MD
This chronic inflammation slowly and sequentially damages the lash follicles, meibomian glands and lastly the lacrimal glands, leading to what has been commonly referred to as dry eye disease or lid margin disease.
When early talks on dry eye blepharitis syndrome began in 2014, the most common question was, “What is biofilm, and why is it on the eyelid margin?” Now, 10 years later, not only have most eye doctors heard of biofilm, but the theory is becoming widely accepted as the most logical explanation for the tear gland damage we see in our patients.
Recently, a novel approach has been developed to address this disease by focusing on the eyelid biofilm.
Patient education is first and foremost. We developed a video that patients must watch before their visit that explains the biofilm theory in detail.
On their first visit, the lid margin biofilm is debrided using a BlephEx device followed the same day by a heat-and-express procedure that allows for pictures to be taken of what is expressed. This is important for additional patient education.
This sounds like it should be simple enough, except that these treatments need to be performed monthly until clear oil is obtained without solidification or cloudiness. During these treatments, the practitioner should also notice the Rynerson red line, a deep red line of inflammation along the upper eyelid just above or below the lash line, gradually diminish as subdermal inflammation gradually subsides and clear oil volume increases. Once clear oil is achieved, the intervals should be increased to 6 weeks, 8 weeks, 3 months and so on as long as the oil remains clear. Once the 6-month mark is reached, that becomes the interval for future treatments to keep the oil clear and patients free of symptoms.
Pictures of expressed meibomian gland contents should be taken at every visit to keep patents engaged and encouraged, which can be a challenge because these treatments are all cash pay. But the combination of quick symptomatic improvement, decreasing redness and photographic evidence of clinical progress will usually convince patients to stay the course.
Both ophthalmologists and optometrists can offer this BlephEx and heat-and-express treatment protocol to their patients, some of which will be hesitant due to the monthly cost. But many will not think twice about it if it can fix the problem and will become your most loyal patients. Remember that many of these patients are miserable and experiencing a decrease in their quality of life. Give them a chance to get better and stay better with this simple yet effective new protocol. The practitioner will look at dry eye differently, currently as a frustrating disease with no explanation and no cure, to the most rewarding part of a practice. If the way you are treating meibomian gland dysfunction is not resulting in a slow resolution of the Rynerson red line and improved tears, then consider this approach. Feel free to email us with any questions or comments, and we will be happy to help institute this protocol in your office.
- References:
- Auw-Hädrich C, et al. Ophthalmologe. 2018;doi:10.1007/s00347-017-0606-8.
- Rynerson JM, et al. Clin Ophthalmol. 2016;doi:10.2147/OPTH.S114674.
- Verjee MA, et al. Ophthalmol Ther. 2020;doi:10.1007/s40123-020-00308-z.
- For more information:
- Hank D. Perry, MD, a corneal, cataract and refractive surgery specialist and partner at Ophthalmic Consultants of Long Island in Westbury, New York, can be reached at hankcornea@gmail.com.
- James Rynerson, MD, CEO of BlephEx, can be reached at docjmrmd@gmail.com.
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