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Making Strides in Blepharitis Treatment How New Insights Can Help Doug Katsev, MD Clinicians Elevate Patient Care by Paul M

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Making Strides in Blepharitis Treatment How New Insights Can Help Doug Katsev, MD Clinicians Elevate Patient Care by Paul M Sponsored by Paul M. Karpecki, OD, FAAO Making Strides in Blepharitis Treatment How New Insights Can Help Doug Katsev, MD Clinicians Elevate Patient Care By Paul M. Karpecki, OD, FAAO; and Doug Katsev, MD Drs. Karpecki and Katsev are paid consultants for Bausch + Lomb. CHALLENGES OF BLEPHARITIS atients suffering from blepharitis Blepharitis is one of the most common ocular are a common, but unique, segment of pathologies encountered in the clinical settings.4 eye care patients. The chronic nature of Reports from US primary eye care providers es- blepharitis and sometimes-confound- timate that approximately 40% of patients seen Ping aspect of its diagnosis can create obstacles present with signs or symptoms of blepharitis.4 to treatment and management of the condition. However, the etiology of blepharitis is poorly In recent years, the Tear Film & Ocular Sur- understood.5 Pathogenesis is hypothesized to face Society Dry Eye Workshop II (DEWS II) re- be multifactorial, to include inflammatory skin port has offered foundational wisdom from 150 conditions, chronic lid margin infections, and worldwide experts on ocular surface care and parasitic infections.6 Symptoms can include a disease management, and provided guidance foreign body or burning sensation, excessive on best practices for management of condi- tearing, itching, photophobia, red and swollen tions such as blepharitis.1 eyelids, redness of the eye, blurred vision, dry In addition, eye care professionals have ac- eye, and scurf on the eyelashes.5 cess to treatments for blepharitis that address Blepharitis is categorized as acute or chronic, the inflammatory and sometimes bacterial as- and also by anatomic location: 1) anterior, which pects of the condition in order to relieve patient affects the exterior of the eyelid at the base of symptoms in a meaningful way. the eyelashes, and is frequently caused by bac- The availability of effective and timely treat- teria (Staphylococcal) and seborrheic dermati- ment can not only help to reduce the signs and tis;5 and 2) posterior blepharitis, which is found symptoms of blepharitis for sufferers, but it can at the posterior lid margin, and is frequently help to target unwanted physical manifesta- caused by meibomian gland dysfunction (MGD), tions of the condition that potentially weigh on infectious or allergic conjunctivitis, acne, ro- the patient’s psyche and negatively impact on sacea and seborrheic dermatitis.5 That said, in their social experience.2,3 patients with infectious blepharitis, the associat- As DEWS II and other consensus documents ed pathogens and resulting inflammation don’t continue to add to the collective body of eye tend to differentiate by location. care knowledge, clinicians can gain valuable Despite its prevalence, blepharitis can be a insights on the most effective ways to care for challenging condition to treat.7 If not adequately their blepharitis patients. With this new infor- addressed, long-term, unmanaged blepharitis mation in mind, they can hope to promptly help can lead to permanent changes to the eyelid alleviate the physical and social-emotional bur- morphology, and visual deficits due to keratop- dens of the condition for those who deal with it. athy and corneal ulceration.6 Blepharitis, in addition to yielding unwanted Please see Important Safety Information on page 6 and full Prescribing Information for ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) on pages 7-8. with BKC had worse meibomian gland function, Caring for the Blepharitis Patient poorer morphology, and a higher rate of medical Here is a short excerpt from our overall protocol histories related to the meibomian gland than a for managing the average blepharitis patient. healthy population.9 Evaluation & Diagnosis • Carefully evaluate the slit-lamp exam for MGD BLEPHARITIS MANAGEMENT & DEWS II and dry eye disease; look for corneal staining The chronic nature of blepharitis and the fre- • Check for conjunctival involvement of follicles quent coexistence of ocular surface disease can and papilla make blepharitis difficult to manage. Foundation- ally, patients who are prone to getting blepharitis Classification should maintain good, routine eyelid hygiene in • Determine acute vs. chronic nature of con- order to prevent flareups. One goal of manage- dition (anterior vs. posterior determination is ment for blepharitis is to keep the lids clean and less critical) free of biofilm. Moreover, blepharitis patients who have concomitant acne rosacea should have the Lid Hygiene and Treatment Strategy • Acute blepharitis: Short burst of combination conditions treated simultaneously. topical antibiotic-corticosteroids The importance of good lid hygiene was • Chronic blepharitis: Lid hygiene, hot com- stressed by the authors of the DEWS II report.1 presses, and lid scrubs; oral antibiotics; The report’s authors highlighted the importance and “episodic use” of combination topical of appropriately managing a variety of lid con- antibiotic-corticosteroids ditions that result in dry eye, particularly bleph- — Drs. Karpecki and Katsev aritis.1 Lid hygiene, if used correctly, the authors wrote, could reduce lipid byproducts and lipolytic physical signs and symptoms for sufferers, can bacteria associated with these conditions.1 In ad- also take a negative emotional toll on patients. dition, the International Workshop on Meibomian One study, a retrospective analysis, found that Gland Dysfunction put forth that lid hygiene has blepharitis patients were at elevated risk of anxi- been widely considered an effective therapy for ety and depression, particularly during the period MGD and blepharitis.10 shortly after diagnosis.2 Another determined that persistently uncomfortable eyes, “an unattractive UPDATES IN LID HYGIENE PRACTICES appearance,” and uneasy feelings experienced by Applying warm compresses to the lids is often blepharitis patients might precipitate psychologi- accepted as an essential first step for maintaining cal stress and negative social implications.3 good lid hygiene. Traditionally, another hygiene strategy that had been employed for blepharitis BLEPHAROKERATOCONJUNCTIVITIS patients for many years had been light scrubbing Blepharokeratoconjunctivitis (BKC), similar to of the eyelids with a cotton swab coated with a blepharitis, is a chronic inflammatory condition mixture of water and baby shampoo. However, of the palpebral margin; however, it also features we have found that, over time, commercial sham- secondary conjunctival and corneal involvement.8 poos can remove natural oils and key mucopro- Signs and symptoms include tearing, photopho- teins from our patients’ meibomian glands. bia, red eye, blepharitis (external hordeola or Furthermore, the DEWS II report noted that meibomian cysts), recurrent chalazia, phlyctenu- outdated lid hygiene practices such as using di- lar conjunctivitis, keratitis, as well as corneal com- luted baby shampoo should be updated by eye plications such as ulceration, neovascularization, care professionals. They specifically revealed that scarring, and perforation.8 diluted baby shampoo has been associated with In our experience, BKC frequently leads to as- reduced ocular surface MUC5AC levels and might sociated ocular surface inflammation, and it have an adverse effect on goblet cell function.11 can exacerbate symptoms of coexisting ocular As a result, the authors strongly advised that surface disease. One study found that patients clinicians utilize newer, more efficacious hygiene Please see Important Safety Information on page 6 and full Prescribing Information for ZYLET® (loteprednol etabonate 0.5% 2 and tobramycin 0.3% ophthalmic suspension) on pages 7-8. strategies available on the market today that utilize a diversity of deliv- Diagnosing BKC vs. Allergic Conjunctivitis or ery mechanisms to improve patient Dry Eye outcomes when it comes to lid hy- It’s important to reduce the risk of ocular complications in con- giene.1 They noted that many new ditions such as BKC and rule out other ocular issues by confirm- products are available to improve ing diagnosis as soon as possible. If dry eye is suspected, a pos- lid health, including scrubs, foams, itive result to a screening questionnaire such as the 5-item Dry solutions, and wipes; however, more Eye Questionnaire (DEQ-5) or the Ocular Surface Disease Index specific information was beyond the (OSDI) should trigger further evaluation.15 Included are our rec- scope of the report.1 ommended steps to follow to try to confirm BKC diagnosis: PATIENT ADHERENCE Medical History Review CHALLENGES Triaging questions16 Research has found that patients • Symptoms and signs who follow clinician-recommended • Time of day when symptoms are worse lid hygiene practices can see symp- • Duration of symptoms tom improvement. In a cross-sec- • Unilateral or bilateral presentation tional study, 207 subjects with dry Dry eye questionnaire15 eye symptoms and margin signs • OSDI were instructed to perform warm • Standard patient evaluation of eye dryness (SPEED) compresses and eyelid scrubs, and Risk factor analysis16 then complete a follow-up phone • Exacerbating conditions survey assessing adherence and • Systemic/autoimmune disease(s) that can contribute or subjective therapeutic response cause BKC 12 six weeks later. Patients who per- • Recent exposure to an infected individual formed the routine noted an im- Clinical examination16 12 provement in symptoms. • Eye chart or visual acuity test However, one challenge for cli- • Skin and eyelids changes
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