Experts offer top blepharitis tips

August 3, 2017

Article

Sometimes you just want to know what the experts do.

Optometry Times is here to help by offering you expert tips on how to manage blepharitis.

We asked industry experts, most of them members of our Editorial Advisory Board, for their top suggestions to colleagues on how to best manage blepharitis.

Eleven thought leaders offer you their guidelines. You’ll see some commonality among them, such as incorporating imaging technology and keeping an eye out for demodex.

Click here for our expert blepharitis tips

Milton M. Hom, OD, FAAO, FACAAI (Sc)

Azusa, CA

Optometry Times Editorial Advisory Board member

1. Ask yourself: Is it blepharitis or is it cylindrical dandruff? This will ultimately determine your treatment path

2. Not all blepharitis has meibomian gland dysfunction (MGD), and not all MGD has blepharitis-lid expression required!

3. Almost all treatments fall into two categories: Anti-inflammatory or obstruction. Use treatments from both.

Up next: Leslie O'Dell, OD, FAAO

Leslie O’Dell, OD, FAAO

York, PA

Optometry Times Editorial Advisory Board member

1. Start the slit lamp exam with lash and lid evaluation. I start with closed eyes to view the top eyelid margin.

2. Take photos! Seeing is believing for these patients, and images are great for adherence to treatment.

3. Read the labels. Before recommending products to patients, be sure you are familiar with the ingredients. Some well-known brands use chemicals, such as alcohol, which are not ocular surface friendly.

4. Always evaluate the meibomian glands for patients with blepharitis.

5. Don’t forget demodex.

Up next: Scott G. Hauswirth, OD, FAAO

Scott G. Hauswirth, OD, FAAO

Denver, CO

Optometry Times Editorial Advisory Board member

1. Understand that blepharitis at any level still likely feeds into the inflammatory dry eye loop; our immune systems are designed to kill things, and unfortunately they can harm good tissues in the process. This makes it important to treat and manage along with any subsequent surface disease.

2. Lid hygiene should be taught to patients at an early age and performed regularly for virtually all patients.

3. Detergent-based cleansers should be avoided because they are hard on the lid margin and cause drying in a sensitive region-the juxtaposition of the keratinized epithelium and the mucous membrane surface of the palpebral conjunctiva.

Up next: Katherine M. Mastrota, OD, FAAO

Katherine M. Mastrota, OD, FAAO

New York City

Optometry Times Editorial Advisory Board member

1. Lid hygiene, lid hygiene, lid hygiene

2. Incorporate omega-3 supplements and promote good nutrition.

3. Refer for a dermatology or allergy consult if blepharitis remains uncontrolled.

Up next: Tracy Schroeder Swartz, OD, FAAO

Tracy Schroeder Swartz, OD, FAAO

Madison, AL

Optometry Times Editorial Advisory Board member

1. Incorporate lid scrubs. I start with over-the-counter (OTC) products first. If patients have a lot of discharge, I move to non-OTC preparations if blepharitis fails to improve in three weeks.

2. Do not use Johnson & Johnson baby shampoo.

3. I recommend hot compresses x 7 minutes to heat up the back of the eyelid. More is required for MGD, but this works to easily remove debris stuck on the lid.

4. For elderly patients, I often use erythromycin to lids nightly because it is easy for them to apply.

Up next: Christine W. Sindt, OD, FAAO

Christine W. Sindt, OD, FAAO

Iowa City, IA

1. Get lids professionally cleaned. Like plaque, there is only so much debris and keratin that can be removed at home.

2. Most people get hot compresses wrong. Use ustained heat at 42ÃÅ¡ Celsius for 10 minutes; do anything less, and it’s not worth doing at all. Regular in-office heat treatments with gland expression help as well.

3. You are what you eat. Consider a non-inflammatory diet such as low carb and low processed foods, and add omega 3 supplements.

Up next: Laura Periman, MD

Laura Periman, MD

Redmond, WA

I teach that MGD and blepharitis is best addressed by understanding “The BEIST.” This is my way to organize the OCEAN paper¹ and the Baudouin et al Vicious Circles paper.²

B: Bacterial and demodex component. Try Avenova (hypochlorous acid, NovaBay) and intense pulsed light (IPL) therapy.

E: Enzymatic compromise. Optimize the meibum biochemistry.

I: Inflammation. Address the inflammatory burden with omegas, immunomodulators, loteprednol (Lotemax, Bausch + Lomb), and IPL.

S: Stasis. Blink. Debride lid margin. Express. Use thermal pulsation (LipiFlow, TearScience).

T: Temperature. Use warm compresses and thermal pulsation.

Up next: Scott Schachter, OD

Scott Schachter, OD

Pismo Beach, CA

Optometry Times Editorial Advisory Board member

1. Using imaging technology. Pictures are important because patients are usually mildly symptomatic.

Related: Understanding and defining MGD

2. Blepharitis is chronic and requires ongoing maintenance.

3. Offer products in-office at competitive prices to increase patient compliance.

Up next: Walter O. Whitley, OD, FAAO

Walter O. Whitley, OD, FAAO

Virginia Beach, VA

Optometry Times Editorial Advisory Board member

1. Look: It is easy to get to the fancy thing called the cornea and retina, but don't overlook the lids.

Related: 4 steps to beating blepharitis

2. Listen: Ask patients about common ocular suface diseasae symptoms such as dryness, blurred vision, or itching. Localize if itching is along the lids (blepharitis) or inner canthus (allergy).
3. Follow: Blepharitis is often a chronic condition. Always treat and follow, which allows you to modify treatment as necessary.

Up next: Andrew S. Morgenstern, OD, FAAO

Andrew S. Morgenstern, OD, FAAO

Rockville, MD

It is important to note to patients is that blepharitis can be both anterior and posterior.

Blepharitis is a chronic condition that will wax and wane even with aggressive treatment. Therefore, treatment never ends. As soon as the patient lets up, it will return.

Although it will vary from patient to patient as therapy, my standard recipe is:

1. Daily heat via Bruder mask to improve positive flow of healthy meibum even after resolution.

2. Daily hygiene via optimized eye lid cleanser such OcuSoft Lid Scrubs (Ocusoft) and hypochlorus acid (Hypochlor, OcuSoft) that can reduce or eliminate bacterial and inflammatory load even after resolution.

3. Continuous use of topical artificial tears, preferably preservative free, and an oral supplement of omega fatty acids such as HydroEye (ScienceBased Health) for improvement of tear film and reduction of dry eye even after resolution.

Most important, ensure your patients return as you deem appropriate for maximal treatment.

Up next: Whitney Hauser, OD

Whitney Hauser, OD

Memphis, TN

1. Don't overlook the lids. The maintenance of lids and adnexa is essential for healthy eyes and is often overlooked as the origin of irritation symptoms.

2. Get the cause correct. Is it seborrheic, staph, or demodicosis? Then treat appropriately for the specific cause.

3. Educate on chronicity. Blepharitis isn’t necessarily a “one-and-done” therapy. Patients need to know that blepharitis may return, and follow-up visits are necessary.

References

1. Geerling G, Baudouin C, Aragona P, Rolando M, Boboridis KG, BenÃtez-Del-Castillo JM, Akova YA, Merayo-Lloves J, Labetoulle M, Steinhoff M, Messmer EM. Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting. Ocul Surf. 2017 Apr;15(2):179-192.

2. Baudouin C, Messmer EM, Aragona P, Geerling G, Akova YA, BenÃtez-del-Castillo J, Boboridis KG, Merayo-Lloves J, Rolando M, Labetoulle M. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016 Mar;100(3):300-6.

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