Dry Eyes and BlepharitisDry Eyes and BlepharitisDry Eyes and BlepharitisDry Eyes and Blepharitis

Mitch Menage

Consultant Eye Surgeon

Leeds Teaching Hospitals Trust

Mitch Menage

Consultant Eye Surgeon

Leeds Teaching Hospitals Trust

GP Meeting Sep 2006GP Meeting Sep 2006

Dry Eyes and BlepharitisDry Eyes and Blepharitis

Common chronic conditions in often

unhappy patients

‘Heartsink’

Common chronic conditions in often

unhappy patients

‘Heartsink’

BlepharitisBlepharitis

Chronic inflammation of the lid margins Common Remitting Range of ages Bilateral Often misdiagnosed as conjunctivitis

Chronic inflammation of the lid margins Common Remitting Range of ages Bilateral Often misdiagnosed as conjunctivitis

BlepharitisBlepharitisBlepharitisBlepharitis Lid anatomy Types Associated conditions Symptoms Signs Treatment

Lid anatomy Types Associated conditions Symptoms Signs Treatment

Lid anatomyLid anatomyMeibomian/tarsal glands

Glands of Zeiss and Moll

Lid anatomyLid anatomy

Blepharitis-TypesBlepharitis-Types

Anterior –staphylococcal/dandruff

Yellow flakes on lid margin

Posterior sebborhoeic Inflamed red oily lid edges

Anterior –staphylococcal/dandruff

Yellow flakes on lid margin

Posterior sebborhoeic Inflamed red oily lid edges

BlepharitisBlepharitis

Staphylococcal BlepharitisStaphylococcal Blepharitis

More common young patients Chronic infection of base of lashes Staph. Aureus Associated with styes Secondary

Papillary conjunctivitis Punctate corneal erosions Marginal keratitis

More common young patients Chronic infection of base of lashes Staph. Aureus Associated with styes Secondary

Papillary conjunctivitis Punctate corneal erosions Marginal keratitis

Seborrhoeic BlepharitisSeborrhoeic Blepharitis

More common older patients Excessive lipid secretion meibomian glands

Meibomitis/MGD

Lid commensals break down to free fatty acids Shiny waxy lids with greasy lashes Secondary

Papillary conjunctivitis Punctate corneal erosions

More common older patients Excessive lipid secretion meibomian glands

Meibomitis/MGD

Lid commensals break down to free fatty acids Shiny waxy lids with greasy lashes Secondary

Papillary conjunctivitis Punctate corneal erosions

Acne RosaceaAcne Rosacea Strongly associated with seborrhoeic blepharitis Mild forms not diagnosed

Strongly associated with seborrhoeic blepharitis Mild forms not diagnosed

Blepharitis-SymptomsBlepharitis-SymptomsBlepharitis-SymptomsBlepharitis-Symptoms

Sore burning itching irritation of lids Grittiness and watering Mild stickiness particularly on waking Red lid margins Dry eyes

Sore burning itching irritation of lids Grittiness and watering Mild stickiness particularly on waking Red lid margins Dry eyes

SignsSignsSignsSigns

Red lid margins Greasy material along margin of lids Clogging of meibomian gland openings Mild conjunctival injection Punctate corneal staining Acne Rosacea Styes/chalazions

Red lid margins Greasy material along margin of lids Clogging of meibomian gland openings Mild conjunctival injection Punctate corneal staining Acne Rosacea Styes/chalazions

ChalazionChalazion

TreatmentTreatmentTreatmentTreatment

Patient education! Lid hygiene Hot compresses

Warm flannel 10 mins Eyebag

Lubricants Antibiotic gel/ointments Oral antibiotic

Intermittent steroid ointment

Patient education! Lid hygiene Hot compresses

Warm flannel 10 mins Eyebag

Lubricants Antibiotic gel/ointments Oral antibiotic

Intermittent steroid ointment

Dry EyesDry EyesDry EyesDry Eyes

Lacrimal apparatus Tear Film Causes/Associated Conditions Symptoms Signs Treatment

Lacrimal apparatus Tear Film Causes/Associated Conditions Symptoms Signs Treatment

Lacrimal anatomyLacrimal anatomyLacrimal anatomyLacrimal anatomy

Causes of Dry EyeCauses of Dry Eye‘Keratoconjuctivitis Sicca’‘Keratoconjuctivitis Sicca’

Causes of Dry EyeCauses of Dry Eye‘Keratoconjuctivitis Sicca’‘Keratoconjuctivitis Sicca’

Lacrimal gland aging

Strongly associated with blepharitis

Inflammatory conditions

Rheumatoid arthritis

Sarcoidosis

Sjogrens Syndrome

Lacrimal gland aging

Strongly associated with blepharitis

Inflammatory conditions

Rheumatoid arthritis

Sarcoidosis

Sjogrens Syndrome

Sjogrens SyndromeSjogrens Syndrome Very severe dry eyes Middle-aged women KCS/Xerostomia and vasculitic disease

Rheumatoid Arthritis SLE Scleroderma Polyarteritis

Blood tests ANA 70% SSA(RO) 70% SSB (LA) 40% RhF 60%

Very severe dry eyes Middle-aged women KCS/Xerostomia and vasculitic disease

Rheumatoid Arthritis SLE Scleroderma Polyarteritis

Blood tests ANA 70% SSA(RO) 70% SSB (LA) 40% RhF 60%

SymptomsSymptoms

Feel dry (Can be watery!) No relation to emotional tearing

Gritty burning eyes Worsening through day peak in evening Worsened by reading, TV, computer Worsened by air conditioning, central heating, dry

arid conditions

Feel dry (Can be watery!) No relation to emotional tearing

Gritty burning eyes Worsening through day peak in evening Worsened by reading, TV, computer Worsened by air conditioning, central heating, dry

arid conditions

SignsSigns

Often none! Poor tear film on SL with rapid break-up time Punctate staining of cornea inferiorly Filament strands of mucus on cornea Schirmers test

Often none! Poor tear film on SL with rapid break-up time Punctate staining of cornea inferiorly Filament strands of mucus on cornea Schirmers test

SignsSignsRapid tear break-up time

SignsSignsRose Bengal staining

SignsSignsMucus Filaments

Schirmers TestSchirmers Test

Treatment - LifestyleTreatment - LifestyleTreatment - LifestyleTreatment - Lifestyle

Avoid dry situations Car Air conditioners Irritants cigarette smoke etc.

Drugs BP, antidepressant, antihistamine etc Increase humidity

Plants, wet towels, radiator trays etc.

Humidity chambers Wraparound glasses Swim goggles

Avoid dry situations Car Air conditioners Irritants cigarette smoke etc.

Drugs BP, antidepressant, antihistamine etc Increase humidity

Plants, wet towels, radiator trays etc.

Humidity chambers Wraparound glasses Swim goggles

Treatment-LubricantsTreatment-LubricantsTreatment-LubricantsTreatment-Lubricants

Liquid drops Frequent application

Gels More blurring

Ointments Usually only at night Nocturnal lagophthalmos

Preservative free?

Liquid drops Frequent application

Gels More blurring

Ointments Usually only at night Nocturnal lagophthalmos

Preservative free?

Liquid LubricantsLiquid Lubricants

Gel LubricantsGel Lubricants

OintmentsOintments

New TreatmentsNew Treatments

TreatmentTreatment

Anti-inflammatory Steroid Cyclosporin –Restasis

Antimucolytic acetylcysteine –Ilube

Oral pilocarpine-Salagen Usually only in Sjogrens Side effects/limited efficacy

Anti-inflammatory Steroid Cyclosporin –Restasis

Antimucolytic acetylcysteine –Ilube

Oral pilocarpine-Salagen Usually only in Sjogrens Side effects/limited efficacy

TreatmentTreatment

Punctal occlusion Cautery Plastic Plugs Smartplugs

Punctal occlusion Cautery Plastic Plugs Smartplugs

Punctal CauteryPunctal Cautery

Simple procedure under L/A Often preceded by temporary trial occlusion Cautery inserted into punctum/canaliculus Sometimes not successful Permanent and difficult to reverse More common to use temporary plugs first

Simple procedure under L/A Often preceded by temporary trial occlusion Cautery inserted into punctum/canaliculus Sometimes not successful Permanent and difficult to reverse More common to use temporary plugs first

Punctal PlugsPunctal PlugsPunctal PlugsPunctal Plugs

SmartplugsSmartplugs

Dry Eyes and BlepharitisDry Eyes and BlepharitisDry Eyes and BlepharitisDry Eyes and Blepharitis

Very common in older patients Chronic remitting problem Not usually serious but constant nuisance Patient Education

Lifestyle Regular hygiene/instillation of drops/gels Realistic expectations of treatment!

Very common in older patients Chronic remitting problem Not usually serious but constant nuisance Patient Education

Lifestyle Regular hygiene/instillation of drops/gels Realistic expectations of treatment!