Recognize link between lid hygiene, dry eye disease
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Anything that happens to the eyelid will directly affect the eye’s surface. As a result, I cannot treat dry eye disease or any pathology on the surface without addressing the eyelids.
I often see patients with overgrowth of normal skin bacteria and Demodex mites in the eyelids, which can lead to ocular surface disease. As bacteria and Demodex create biofilm, the levels of inflammatory proteins and cytokines rise, triggering the cascade of inflammatory events that causes dry eye disease. The unstable tear film triggers additional inflammation, feeding a vicious cycle.
Here’s how I treat eyelids and dry eye disease as one closely linked system to minimize that vicious cycle.
Evaluate the skin, eyelids
To understand what’s going on with a patient’s eyes and eyelids, I start by grossly assessing the face, nose and eye area, looking for skin irregularities such as color changes, dryness, dermatitis or telangiectatic vessels. Next, I look for eyelid abnormalities, malpositions, growths, scar tissue or visible vessels. I also want to assess whether the patient has telltale signs of skin conditions that contribute to ocular surface disease — most notably rosacea, which causes facial redness and telangiectatic vessels and is strongly associated with inflammatory dry eye disease. (I see many patients who know they have rosacea but don’t realize there can be an ocular component.)
Once I carefully observe the patient’s appearance, I examine the eyelids in detail through the microscope. I’m looking for eyelid swelling, erythema, collarettes, eyelash debris or scurf, makeup debris, edema at the base of the eyelash follicles, eyelash loss, telangiectatic vessels, hyperkeratinization of the lid margin, deficient meibomian gland expressibility, poor meibum quality, eyelid malformation or scarring. I also use meibography to assess the quantity and structure of the glands.
Blepharitis is defined by inflammation and swelling of the eyelids regardless of whether scurf or debris is present. Collarettes and scurf may point to Demodex. Eyelid malposition, scarring or swelling — often accompanied by conjunctival injection — usually indicate chronic, untreated blepharitis.
The rest of the assessment is a straightforward ocular surface disease exam, combining a slit lamp examination with tests such as tear breakup time, corneal and conjunctival staining, tear meniscus height, and osmolarity to characterize the patient’s dry eye disease.
Treating two interconnected problems
Today, it’s essential to rely on in-office treatments for dry eye and eyelid margin conditions more than we did in the past. When we burden patients with extensive at-home care, including the need to use eye drops throughout the day, we force them to think about their eyes at all times, which is psychologically counteractive. Also, increasing the at-home treatment burden decreases the chances of compliance and, as a result, the chances of successfully managing the problem.
My foundational treatments for patients with eyelid pathology and dry eye disease are in-office debridement with microexfoliation (BlephEx) and light-based treatment (OptiLight, Lumenis) to target inflammation. I use BlephEx first, so additional therapies start with clean eyelids. BlephEx deep cleans the eyelash base and eyelid margin, minimizing bacteria, mites, debris and biofilm in just a few minutes. I determine the frequency of the procedure based on the patient’s underlying condition and its severity, varying from once a year in mild cases to two to three times a year in moderate to severe cases.
OptiLight is ideal for these patients because it addresses inflammation and other factors that overlap with the lid margin in treating dry eye disease. OptiLight is performed on the periocular area, where it destroys the abnormal (telangiectatic) vessels that perpetuate inflammation. It reduces the bacteria and Demodex loads, minimizing the biofilm they produce and decreasing inflammatory cytokines. It also restores meibomian gland function, allowing patients to make the healthy meibum needed to achieve a stable tear film. OptiLight’s positive effects on the eyelids originate from its ability to break the inflammation cycle that underlies dry eye disease. It’s comfortable for my patients, who have four 10- to 15-minute OptiLight treatments spaced 2 to 3 weeks apart, with maintenance treatments later if needed. Patients get an effective solution that reduces the burden of at-home care, including frequent use of eye drops.
Many options for medications, supplements and hygiene products make it possible to tailor home care for eyelid hygiene. First, I recommend a warm compress to soften the eyelid scurf. Next, I recommend a hypochlorous acid solution, which is naturally anti-inflammatory and antimicrobial. For patients with Demodex, I may also recommend a tea tree oil formulation (Blephadex, Lunovus) that has a soothing, moisturizing component to improve tolerance. Azithromycin 1% topical antibiotic reduces inflammation for blepharitis. It is highly bioavailable, so patients only need to use two drops a day for the first two days, then reduce it to one drop a day.
In addition to BlephEx and OptiLight, I recommend patients with lid margin disease and dry eye take omega 3 supplements to improve their meibum production. In most patients with blepharitis-related dry eye disease, I start a 2- to 3-week course of a topical antibiotic and anti-inflammatory combination (tobramycin 0.3%, dexamethasone 0.05%). In moderate to severe blepharitis cases or those associated with rosacea, I recommend an oral antibiotic (doxycycline 50 mg once a day) before we initiate OptiLight as a root-cause therapy. If needed, and if the patient is willing and able to use eye drops twice daily, I can prescribe chronic therapy with cyclosporine (Cequa, Sun Pharmaceutical; Restasis, Allergan) or lifitegrast (Xiidra, Novartis).
In cases with eyelid abnormalities such as entropion, ectropion or increased lid laxity, I always recommend a consult with oculoplastics. Abnormal lid positioning will perpetuate the vicious cycle of dry eye if not addressed.
Make eyelid hygiene routine
We’ve talked a lot in the dry eye space about the “dental model” — that patients should take care of their eyes every day, just like they brush their teeth. This comparison is especially appropriate for eyelid hygiene because it removes biofilm, and dental plaque is also a biofilm. I tell patients that if they don’t remove overgrowth of biofilm and debris, not only will their eyes feel worse, but their untreated chronic blepharitis and dry eye can also lead to corneal epithelium breakdown, recurrent corneal erosions and corneal scarring, eventually causing vision loss. Using meibography to demonstrate patients’ meibomian gland structure and showing an image of Demodex mites both go a long way to securing compliance.
Keeping the eyelids clean is part of the comprehensive treatment for dry eye disease. Making it routine after BlephEx and OptiLight helps limit progression and flare-ups that disrupt patients’ quality of life.
For more information:
Nabila Gomez, OD, FAAO, specializes in the evaluation and management of vision correction surgery, cataract surgery, dry eye disease, ocular surface disease and glaucoma at Dell Laser Consultants in Austin, Texas.
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