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Protocols for lid disease treatment differ among ODs
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Although treatment protocols for eyelid disease tend to vary among practitioners, certain established approaches exist for managing this condition in long-term sufferers.
Measures such as lid hygiene, nutritional supplements and oral and topical medication can keep lid disease flare-ups at bay, practitioners claim.
Lid hygiene, shampoo use
For those with a history of meibomianitis or blepharitis, prophylactic measures are required to prevent recurrences. One of the fundamental aspects of lid disease prophylaxis is ongoing lid hygiene.
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The use of lid scrubs with shampoo is a source of some debate among practitioners. Although this method was once ubiquitous, it has raised concerns over the destabilization of the tear film.
“Years ago, we didn’t have anything really good with which to scrub eyelids,” William D. Townsend, OD, a practitioner in Canyon, Texas, told Primary Care Optometry News. “We wanted to use something that had a detergent or surfactant quality to break up the oils and remove them along with the bacteria. Someone recommended baby shampoo, because it doesn’t sting the eyes.”
Dr. Townsend added, however, that he considers the use of baby shampoo to be obsolete in light of newer products. “Baby shampoo is actually quite irritating, but at the time there was nothing else,” he said. “Now, with the introduction of real lid scrubs that are actually designed for the eyelid surface, there is just no reason to use baby shampoo.”
Dr. Townsend described these scrubs as “a kinder, gentler way to treat eyelid disease.”
“They are not expensive, and you can use one pad for two eyes,” he said. “I personally like OcuSoft Lid Scrubs (Cynacon/OcuSoft, Richmond, Texas); I find that their scrubs are very gentle.”
According to George W. Comer, OD, MBA, FAAO, associate professor and chief of staff at the Optometric Center of Fullerton in Fullerton, Calif., lid scrubs with shampoo can also be problematic from a compliance standpoint.
“I may recommend it, but a lot of patients just don’t really do it,” he said.
Adjunct ointments for treatment
Practitioners have found that the use of ointments, either antibiotic or antibiotic/steroid combinations, can be helpful as an adjunct therapy for eyelid disease treatment.
“I do use antibiotic ointment, but it depends on how inflamed the eyelid margin is,” Dr. Comer said. “If it is touchy, sensitive and painful, lid hygiene will not work. I use bacitracin, or I might use erythromycin, but I use bacitracin a lot more often.”
Dr. Comer said he also might try a steroid/antibiotic combination and said he most often reaches for TobraDex (tobramycin dexamethasone, Alcon). “That is my drug of choice, although tobramycin does not have the greatest coverage of Staphylococcus, which is the real culprit in lid disease,” he said. “At the same time, it works pretty well for knocking down the inflammatory component.”
Dr. Townsend said if patients comply in using eyelid scrubs, this often eliminates the need for further treatment, but he also uses ointments as needed.
“Remember, you have external lid disease and internal ocular surface disease,” he said. “When bacteria are present, they release substances, which probably include cytokines, and those stimulate an inflammatory response along the lid margin, including the meibomian glands.”
Dr. Townsend explained that if the colonization of bacteria can be reduced by scrubs alone, this helps eradicate the problem.
“But if this doesn’t work, I typically put those patients on an antibiotic/steroid ointment. We will have them rub it into their eyelid margins,” he said. “With most people, though, you don’t put it in the eye. Rather, you have them wash their hands, put it on the tip of their index finger, and rub it into their lash line.”
TobraDex is also Dr. Townsend’s first choice of antibiotic/steroid combinations. When rubbed into the lash line, he said TobraDex gives the patient a sustained effect. He added that it is important to look for an induced steroid response in the patient.
“Some people can get a mild steroid response, others may have marked IOP elevations even with lid-only applications,” he said. “We try not to leave people on steroids too long, because it can also affect the skin. So once we get the inflammation under control, we can usually just use lid scrubs.”
Tetracycline and doxycycline
The use of tetracycline and doxycycline for treating eyelid disease is the source of some debate among practitioners.
“I have participated in roundtable discussions with extremely bright practitioners whom I respect a lot, and we have all had different ideas on this subject,” Dr. Townsend said. “For the loading dose of tetracycline, I use the normal 250 mg four times daily. But then I cut back to once a day, and patients really seem to get the same effect.”
Dr. Townsend pointed out that certain groups of patients cannot take tetracycline or doxycycline – specifically, children and pregnant women.
Dr. Comer said he prescribes doxycycline for severe cases.
“In cases where a patient has a nasty blepharitis that is not responding, I will use the doxycycline,” he said. “I will use 100 mg, twice a day, for 4 weeks. Then, I will drop down to 100 mg once a day for 4 weeks and then see where we are at that point.”
Primary Care Optometry News Editorial Board member Milton Hom, OD, FAAO, said he uses oral medications when he sees recurrent problems with meibomianitis. He said he avoids tetracycline due to its side effects.
“For doxycycline, I prescribe 100 mg once a day for 6 weeks, tapered to 50 mg for 4 weeks, then 50 mg every other day, then gradually discontinued,” he said. “Some patients require a maintenance dosage. I’ll use oral medications when there are recurrent problems with meibomianitis.”
Warm compresses
Dr. Townsend said that warm compresses continue to be an excellent way to manage lid disease. “They literally melt the thickened oil,” he said.
Dr. Townsend said he has found that baby socks work very well as warm compresses. He recommends putting 2 to 3 tablespoons of rice or beans in a clean sock and tying a string or ribbon around the sock above the rice. “This is the compress the patient will use to apply heat to the eyelid,” he said.
The patient is then instructed to put the compress in a microwave and heat for a maximum of 30 seconds. The compress should be hot, but not hot enough to cause pain or discomfort.
The compress should then be applied to the affected eye for a minimum of 3 minutes. As soon as the compress is removed, the patient is instructed to gently but firmly massage both upper and lower eyelids of the heated eye.
“We have found that baby socks hold heat well,” Dr. Townsend said. “They are not messy like water, and they are reusable. When the compress stops working, the patient dumps it out and puts new beans in it.”
Omega-3 supplementation
The use of omega-3 supplementation is also becoming prevalent in the treatment of chronic lid disease, according to the practitioners.
“Omega-3s work for many people,” Dr. Townsend said. “The average American diet is horribly deficient in omega-3s, they promote the ‘good’ prostaglandins.”
Although Dr. Townsend has not conducted a formal study on the efficacy of omega-3s in treating lid disease, he has been observing their effects on his patients. “We have done an in-clinic study where we have observed a very good response in patients with severe meibomian gland disease,” he said. “And it is also good for general dry eye patients.
“TheraTears Nutrition (Advanced Vision Research, Woburn, Mass.) has recently been introduced,” Dr. Townsend continued. “It is a convenient way to prescribe omega-3s of known content and quality for your dry eye patients.”
Dr. Comer said he has used flaxseed oil on increasing numbers of his dry eye patients. “In fact, I am almost to the point where I am reducing the number of patients on which I perform punctal occlusion and try to go with flaxseed oil instead.”
Dr. Townsend said he recommends 1,000 mg of omega-3 twice daily in capsule form. He also suggests an increase in the dietary intake of omega-3s.
“Any cold-water fish contains abundant omega-3s, and it is also present in legumes,” he said. “So people who don’t want to take pills can increase their intake that way.”
For Your Information:
- William D. Townsend, OD, can be reached at 1801 4th Avenue, Canyon, TX 79016-0001; (806) 655-7748; fax: (806) 655-2871.
- George W. Comer, OD, MBA, FAAO, can be reached at 2575 Yorba Linda Blvd., Fullerton, CA 92831; (714) 449-7405; fax: (714) 992-7811.
- Milton Hom, OD, FAAO, can be reached at 1131 East Alosta Ave., Azusa, CA 91702-2740; (626) 963-7100; fax: (626) 335-1402.
- Drs. Townsend and Hom have no direct financial interest in the products mentioned in this article, nor are they paid consultants for the companies mentioned. Primary Care Optometry News could not determine if Dr. Comer has any direct financial interest in the products mentioned in this article, or if he is a paid consultant for any companies mentioned.