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Blepharitis and the Sjögren's Patient

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Blepharitis and the Sjögren's Patient Volume 28, Issue 10 November 2010 Blepharitis and the Sjögren’s Patient by Gary N. Foulks, MD, Arthur and Virginia Keeney,Professor of Ophthalmology, University of Louisville, Louisville, KY lepharitis, one of the most common problems seen by eye care specialists, may affect as many as 30 mil- The SSF Announces Blion Americans.1 Its prevalence increases with age, though eye care specialists are seeing it more in young- 2010 Research Grant Recipients – er patients. Most significantly, this condition appears to be more prevalent in Sjögren’s syndrome patients.2,3 If left untreated, blepharitis can impact a patient’s Donations Made the Difference! eye health, appearance, contact lens use, and quality by Katherine Hammitt, SSF Vice President of Research, and of life. Unchecked blepharitis can compromise results Cynthia Williamson, SSF Research Associate of cataract or LASIK surgery. e are experiencing a distressing dichotomy in research What is Blepharitis? with more scientific opportunities in Sjögren’s than ever Blepharitis involves inflammation of the eyelid.4 It Wbefore that are ripe for research, and yet, with tough economic times experienced in the U.S. and throughout can be caused by a variety of factors (e.g., age, allergy, the world, the future of medical and scientific research is immune system problems, hormone changes, bacteria, uncertain. The National Institutes of Health, the federal and dermatitis). agency and largest dispenser of research funds in the world, Symptoms can range from irritation and redness of reports that the percentage of research grant applications the eyelid margin to problems with reading, using a that are funded by the NIH has dropped from 40% to computer, or watching television. It is more common 20% over the last 30 years. At the same time, the National to see blepharitis as lid margin disease. This condition Health Council reports that 37% of non-profits surveyed can affect the front (anterior) or the back (posterior) this year say they were cutting funds for research. of the eyelid. Many patients experience both forms “We are very fortunate that the Sjögren’s continued page 4 t (Figure 1). continued page 2 t In This Issue 7 Information You Requested 9 I Stood Up 14 In Memory & In Honor 2 November 2010 / The Moisture Seekers “Blepharitis” continued from page 1 t Table 1: Comparison of Anterior and Posterior Blepharitis Anterior Posterior Etiology Bacteria MGD, Aging, Sjögren’s Dermatitis Hormone changes Founded by Immunologic effects Elaine K. Harris in 1983 Presentation Irritation Vision problems Board of Directors Crusty eyes Dry eye Chairman of the Board Collarette Lynn M. Petruzzi, RN Inflammation/redness Chairman-Elect Sjögren’s Not necessarily Definite link S. Lance Forstot, MD Treatment Lid hygiene Lid hygiene Treasurer Doxycycline (oral) Lid massage Kathryn L. McCarren Azithromycin (topical) Lipid containing artificial tears Secretary (Azasite®) (Systane® Balance Lubricant Fred R. Fernandez Antibiotic/Steroid Tears) Immediate Past Chair (TobraDex® ST Suspension Doxycycline (oral) Gary Foulks, MD, FACS Azithromycin (topical) ® Estrella Bibbey (Azasite ) Pamela S. Brown Cyclosporin (in moderate-to- Steven E. Carsons, MD severe cases) Nancy L. Carteron, MD, FACR (Restasis®) Troy E. Daniels, DDS, MS Peter C. Donshik, MD (Courtesy K. Nichols, OD, PhD) Kenneth Economou Figure 1: Overlap of Anterior / Posterior Blepharitis Denise Faustman, MD, PhD Mary W. McNeil Austin K. Mircheff, PhD Nelson L. Rhodus, DMD, MPH Shari Rood Vidya Sankar, DMD, MHS Medical & Scientific Advisory Board Anterior Mixed Posterior Chairman Elaine Alexander, MD, PhD Figure 2: Collarettes Anterior blepharitis is caused by an Richard Brasington, MD imbalance of bacteria normally found Steven E. Carsons, MD on the lid. The most common involve Troy E. Daniels, DDS, MS the Staphyloccus family (e.g., S. epi- H. Kenneth Fisher, MD, FACP, FCCP didimis and S. aureus). These bacteria Gary Foulks, MD, FACS Philip C. Fox, DDS release toxins which can cause eyelid Tara Mardigan, MS, MPH, RD inflammation, redness, irritation, Austin K. Mircheff, PhD crustiness, eyelash debris or collar- John Daniel Nelson, MD, FACS ettes (Figure 2), and eyelash loss. Kelly Nichols, OD Posterior blepharitis involves the inside or back portion of the lid margin. Athena Papas, DMD, PhD Ann Parke, MD A problem with sebaceous glands known as meibomian gland dysfunction Andres Pintos, DMD (MGD) is the most common cause. MGD is more common in patients Nelson L. Rhodus, DMD, MPH with rosacea. Factors that can contribute to MGD include advancing age Daniel Small, MD, FACP and hormone changes. In patients with MGD, the meibomian gland secre- Neil I. Stahl, MD tions contain an abnormal or absent lipid. This abnormality destabilizes the Pamela Stratton, MD Frederick B. Vivino, MD, FACR tear film and can lead to evaporative dry eye, the most common type of dry eye. While MGD can initially appear without inflammation, it will often Chief Executive Officer progress to a more inflamed condition. Steven Taylor ® Moisture Seekers Editor The Moisture Seekers Newsletter is published by the Sjögren’s Syndrome Foundation Inc., 6707 Democracy Adam Gerard Blvd., Ste 325; Bethesda, MD 20817. Copyright ©2010 Sjögren’s Syndrome Foundation Inc. ISSN 0899-637. DISCLAIMER: The Sjögren’s Syndrome Foundation Inc. in no way endorses any of the medications, treat- e-mail: [email protected] ments, or products mentioned in advertisements or articles. This newsletter is for informational purposes www.sjogrens.org only. Readers are advised to discuss any research news, drugs, treatments or products mentioned herein with their health care providers. November 2010 / The Moisture Seekers 3 Why is blepharitis relevant to What is available for Sjögren’s with blepharitis? patients with Sjögren’s? Lid hygiene is a cornerstone in controlling anterior and A study conducted in Japan found that patients posterior blepharitis. Patients should use a cotton ball or with Sjögren’s syndrome are at increased risk of getting lid scrub to remove crusts from the eyelashes every day. blepharitis, particularly posterior disease or MGD.2,3 MGD patients should apply hot compresses to help melt As Sjögren’s is more common in women than in men, secretions from the glands, and then gently massage the blepharitis is most likely due to changes in androgen lid with their fingertips to express the secretions. and estrogen balance following menopause. Immu- With anterior blepharitis, treating the underlying nologic changes may also play a role. Together these bacterial problem and controlling inflammation are crucial. Treatment is directed at the base of the eye- factors alter the meibomian gland. lashes, using an antibiotic such as topical erythromycin Blepharitis can be problematic in Sjögren’s patients, or topical azithromycin (AZASITE®) or an antibiotic causing irritation and evaporative dry eye. In the past, with an anti-inflammatory, such as TOBRADEX® Sus- it was generally thought that Sjögren’s patients had dry pension and TOBRADEX® ST Suspension (sidebar). eye primarily due to aqueous deficiency. If patients do In posterior blepharitis, bacteria secrete enzymes not have enough tears, the higher rate of evaporation and toxins that can contribute to inflammation. Antibi- produces symptoms earlier. Likewise, if patients have otics may be used here, typically topical azithromycin evaporative dry eye and cannot make enough tears, or oral doxycycline. they will have aggravated symptoms. Artificial tear therapy is an important part of manag- ing MGD and posterior blepharitis due to the associated What does your eye care doctor look for? tear instability and evaporative dry eye. The ideal tear The classic symptom of anterior blepharitis is irrita- should contain a component to thicken the tear film lip- tion of the eyelid. Patients also commonly experience id layer and another to reduce evaporation. SOOTHE® crusting, accumulation of debris on the eyelashes, and and FRESHKOTE® are examples of such products. redness at the base of the eyelashes. This fall, SYSTANE® Balance Lubricant Eye Drops Posterior blepharitis can be more subtle. Patients was released to the market for dry eye patients with may not notice any irritations or inflammation in the MGD. My experience from two small clinical studies eyelid, but they often complain of difficulties associated involving Sjögren’s and MGD patients is that these with reading, using a computer, or watching television. drops are well-tolerated and preferred by most patients During an exam, the eye specialist usually looks at to their previous lubricants. With more experience the patient’s eyes through a slit lamp, a microscope-like emerging with this product, I find myself using it more instrument, to view the eye in more detail. In patients as a tear-stabilizing agent. with MGD, the doctor will see plugged glands and For patients with more moderate-to-severe disease thickened secretions (Figure 3). The doctor also will not responding to initial treatments, topical cyclospo- see very rapid tear film breakup (5 seconds or less), a rine (RESTASIS®) is an additional option. prominent sign of MGD. Should I discuss with my eye care Figure 3: Plugged Meibomian Glands/ doctor regarding blepharitis? Expression of Meibomian Glands Sjögren’s patients need to tell their eye doctor about any problems they have with reading, using a com- puter, or watching television. They should also let the doctor know about any eyelid crusting or redness. As the discussion should involve a two-way conversa- tion, patients should ask their doctors a few key questions: • Do you see any evidence of MGD? • Does my tear film appear stable? Would it be appro- The doctor often will press on the eyelid to “express” priate for me to use a lipid enhanced artificial tear the secretions to determine if the glands are producing such as SYSTANE® Balance Lubricant Eye Drops? lipid, and see what it looks like. The doctor notes how • Am I a candidate for an antibiotic like oral doxycy- easily the secretion comes out, and if the secretion is cline or topical azithromycin or a combination like cloudy, with debris, and is thick, like toothpaste, in TOBRADEX® ST Suspension? advanced cases.
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