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Panel: Treating asymptomatic lid disease improves comfort, long-term results
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Start with hot compresses
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Eric E. Schmidt, OD: This clinical dilemma can best be answered by asking one simple question. Does not treating the disease pose a risk to the patient’s ocular health? Most of us would answer “yes” to that question, so the bigger quandary becomes how aggressively you should treat this condition.
At a minimum I would recommend hot compresses to the lids. This will soften the meibum and allow for better spontaneous expression.
For my clinical examination I would concentrate on two factors. I would examine the cornea for sodium fluorescein staining and, if present, I would prescribe a steroid, such as Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) or FML (fluorometholone, Allergan) or steroid/antibiotic combination for at least 2 weeks until I see total resolution.
I also look for lid telangiectasia, which denotes chronicity and needs to be treated. If this is present I recommend AzaSite (1% azithromycin ophthalmic solution, Inspire). AzaSite has anti-inflammatory properties that help short-circuit the inflammation and make the patient feel better. It also decreases meibomian gland inspissation and helps resolve corneal staining.
I would also recommend looking closely at the skin and ocular adnexa of the patient for signs of acne rosacea. If this is present I would prescribe doxycycline 50 mg daily for at least 3 months along with some topical therapy, such as AzaSite or Optive (Allergan, Irvine, Calif.) depending on the state of the patient’s cornea.
Another tool I use is to photograph the patient’s eyelids and ocular surface and show them the image. If lid debris or clogged meibomian glands are visible, this will add further credence to your treatment plan and likely increase patient compliance. I rarely leave the decision to treat or not in the hands of the patient.
For more information:
- Eric E. Schmidt, OD, is president of Omni Eye Specialists in Wilmington, N.C. He can be reached at (910) 793-2010; e-mail: schmidtyvision@msn.com. Dr. Schmidt has no direct financial interest in the products he mentions, nor is he a paid consultant for any companies he mentions.
Treat all, treat early
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William Townsend, OD, FAAO: The potential impact of long-standing meibomian gland disease was poorly appreciated 20 years ago, and hence only a handful of practitioners recognized and treated this condition. We now understand the profound influence of adequate meibomian gland secretions on ocular comfort and quality of vision. We are now seeing the unfortunate impact of decades of untreated meibomian disease. Now many patients have advanced lid disease with significant loss of meibomian gland structure.
Signs of long-term meibomian gland disease include lid margin neovascularization, notching and lack of secretions upon expression. Loss of meibomian glands may be confirmed through transillumination of the lid structures. Transillumination may reveal total or partial loss of secreting acini. Once areas of meibomian gland loss are lost, they do not appear to regenerate.
Many patients with early or moderate meibomian gland disease are asymptomatic or have minimal symptoms. This is particularly true in individuals who still have good aqueous layer production.
We treat all patients with active meibomian gland dysfunction to prevent ongoing inflammation and tissue damage. Therapeutic modalities such as warm compresses, lid expression, systemic tetracyclines, oral omega-3 essential fatty acids and cyclosporine A have been shown to positively affect meibomian gland disease. While the immediate benefits of therapy such as increased gland output and visual enhancement are desirable, the real benefits of long-term therapy (preserving meibomian gland function and preventing atrophy) are the real effects that the patient will appreciate years later.
The management of lid disease is particularly challenging because although the provider may recommend appropriate treatment, the task of carrying out the administration of the various therapies falls on the patient. Early detection and treatment may save him or her from the discomfort and annoyance of advanced meibomian gland disease years later.
For more information:
- William Townsend, OD, FAAO, practices at Advanced Eye Care in Canyon, Texas, and is an adjunct professor at the University of Houston College of Optometry. He can be reached at 1801 4th Ave., Canyon, TX 79015; (806) 655-7748; fax: (806) 655-2871; e-mail: drbilltownsend@gmail.com.
Use targeted off-label treatment
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Blair Lonsberry, OD, MS, MEd, FAAO: The question of treating asymptomatic blepharitis or meibomianitis recently came up in a group discussion of several prominent optometric physicians. It was a heated debate, and at the time I was on the side of not treating. Until recently, our treatment protocols for these conditions were primarily palliative in nature, including warm compresses and lid scrubs. As a person suffering from blepharitis, I can say that warm compresses are an annoyance, particularly if you are asymptomatic.
For patients who are symptomatic, we typically prescribe oral doxycycline for 6 to 8 weeks. This treatment seems excessive for asymptomatic patients. However, with recent evidence that topical compounds such as AzaSite and Restasis (0.05% cyclosporine ophthalmic emulsion, Allergan) benefit these conditions, our options have shifted from simply prescribing palliative care to treatment without the need for prolonged systemic therapy.
With topical regimens such as AzaSite that allow a targeted treatment for blepharitis, I have begun to prescribe this for patients who have no complaints. Often when I start to outline what I am seeing and make my recommendation to the patient, they inevitably will comment on eye irritation or discomfort that they thought was just normal. This is particularly true for my contact lens patients, where upwards of 50% suffer from some sort of eye discomfort associated with their contacts. I find that I am much more observant of the patients’ overall lid hygiene and health and recommending treatment before changing lenses or solutions, especially if the patient was previously successful with that contact lens system.
Currently, AzaSite, as well as Restasis, is an off-label treatment option for blepharitis and meibomianitis. However, with evidence growing that drugs such as these are proving beneficial and offering our patients an actual treatment vs. palliative care, I have begun prescribing treatment to previously asymptomatic patients. My “go to” treatment plan includes the standard warm compresses and lid hygiene (preferably with some type of commercial lid scrub) and AzaSite twice daily for 2 days and then once daily for the next few weeks. It is the treatment plan I put myself on.
For more information:
- Blair Lonsberry, OD, MS, MEd, FAAO, is clinic director at Portland Vision Center, Pacific University College of Optometry. He can be reached at 511 SW 10th Ave., Suite 500, Portland, OR 97229; (503) 352-2510; fax: (503) 352-2525; e-mail: blonsberry@pacificu.edu. Dr. Lonsberry has no direct financial interest in the products he mentions. He is a paid consultant for Inspire.
Educate patients first
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Scot Morris, OD, FAAO: When I treat asymptomatic patients with signs of blepharitis, I take the basic philosophical approach that no patient ever starts with severe lid margin disease. Most patients start with a mild case that, left untreated, progresses to more severe forms. That being said, I explain to patients with lid margin disease that an infection or inflammation of the lid margin left untreated can progress to significant symptoms that include itching, burning, chronic redness and uncomfortable contact lens wear and that it can also make other conditions such as dry eye worse. After a thorough explanation most patients decide to pursue treatment.
If the initial findings are observed during a vision exam, I bring the patient back for a medical follow-up within a few days so that we can perform more thorough testing, as well as discuss the various treatment options.
There are six forms of blepharitis. How I manage the blepharitis depends on the severity and type of blepharitis present.
For seborrheic and posterior forms of blepharitis I start with lid hygiene and hot compresses and then progress to topical AzaSite every 12 hours, 20 mg of oral doxycycline and 2,000 mg to 3,000 mg of oral omega-3 fatty acids. For the anterior forms of blepharitis I start with lid hygiene and topical azithromycin or bacitracin ointment. For complex or mixed forms I typically will do a combination of the above described methods. I then bring these patients back at 3- to 4-week intervals until the lid margin disease has cleared.
For more information:
- Scot Morris, OD, FAAO, can be reached at Eye Consultants of Colorado, 10791 Kitty Drive, Suite B, Conifer, CO 80433; (303) 250-0376; fax: (303) 816-7218; e-mail: smorris@eccvision.com. Dr. Morris has no direct financial interest in the products he mentions. He is a paid consultant for Inspire.
Patients may not really be asymptomatic
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Christine W. Sindt, OD: Patients are not always as asymptomatic as they seem at first glance. Asymptomatic and completely satisfied are two different things. I ask patients about dryness, contact lens wearing time and red eyes. I always discuss my findings, as well as the risks of doing nothing and benefits of treatment.
Foaming eyelid cleansers, such as OcuSoft Lid Scrub Foaming Eyelid Cleanser (OcuSoft, Rosenberg, Texas) make it easy for patients to treat mild blepharitis in the shower. It is surprising how many asymptomatic patients return much happier, simply with a minimal routine change.
For more information:
- Christine W. Sindt, OD, is associate professor of clinical ophthalmology and director of the Contact Lens Service at the University of Iowa Department of Ophthalmology and Visual Sciences, 200 Hawkins Dr., Iowa City, IA 52242; (319) 356-4816; fax: (319) 384-5631; e-mail: christine-sindt@uiowa.edu. Dr. Sindt has no direct financial interest in any products she mentions, nor is she a paid consultant for any companies she mentions.