Going ‘back to basics’ effective for most cases of blepharitis
If conservative treatment is unsuccessful, azithromycin may be introduced.
Staying with my “back to basics” theme after returning from my all-too-short summer sojourn at the beach, I thought it appropriate to talk about one of the most fundamental problems we face when treating dry eye syndrome and ocular surface disease: blepharitis.
When I think back on my days as a resident at New York University, the most indelible memory I have is explaining blepharitis to patients — what it is and how it is treated — and how many times I recited the same story each day in the eye clinics. Blepharitis probably taught me more about patient communication than any other single thing in my residency.
The diagnosis and treatment of blepharitis, like dry eye syndrome (DES), is in a kind of Renaissance period. We can thank the late, much-lamented company Inspire and the promotion of AzaSite (azithromycin ophthalmic solution, Akorn) (more on this in a bit).
For decades, all blepharitis was considered roughly the same, and the treatment was simple, straight-forward, inexpensive and effective, to a point. Think back to how you diagnosed and treated blepharitis. Your patient either had it or not. There was no differentiation between anterior or posterior blepharitis, and only a cursory exploration for the presence of seborrhea was done, if at all.
Once diagnosed you launched into your script: “Blepharitis is caused by an overgrowth of naturally occurring bacteria on our eyelids. It causes redness and irritation and sometimes blocks the openings of the oil glands in your lids. The treatment is what we like to refer to as ‘grandmother medicine’: warm compresses and really careful lid cleaning. It’s not very sexy or exciting or expensive, but it’s very effective.”
Mechanical treatment, that is, “grandmother medicine,” is still a foundation of good blepharitis treatment. It should be the first thing you or your staff discuss with each patient.
Advances in treatment
Next came nighttime ointment, and here you had to take a little bit of a gut check: steroid or no steroid? Most of us were taught to start with an antibiotic ointment applied to the lid margins and just inside the lower lid at bedtime. Bacitracin and erythromycin were, and still are, the first-line antibiotics. Newer, more exotic medicines were introduced in the 1980s, but if you were treating much blepharitis at all, you quickly realized that patients who did not respond to the “bland” antibiotic ointments needed something containing a steroid. Remember Maxitrol (neomycin, polymyxin B sulfates and dexamethasone ophthalmic suspension, Alcon)? That stuff was like miracle juice for cases that defied an easy fix. Except for the pressure spikes and allergy to neomycin, that is.
Still, we did OK for the most part making the majority of our patients feel better, at least as far as their eyelids went. Things got a little easier when we realized that patients with seborrhea who were put on low doses of doxycycline or minocycline (50 mg/day) by their dermatologists not only had a dramatic reduction in eyelid symptoms, but those among them who also had eye inflammation seemed to have fewer of those symptoms, too. This, too, should still be a part of our basic blepharitis treatment armamentarium because it is cheap and effective. But when you write a prescription, be sure to remember that both doxycycline and minocycline are, indeed, systemic medications and that they have both systemic side effects and drug interactions with some rather common medications.
Here is where things got interesting. Do patients get better because of the antibiotic action of these medications, or do these medications decrease or change the lid flora? How about the effect we see on patients with DES, specifically those people we now diagnose with dysfunctional tear syndrome or evaporative dry eye? Is improvement due to a change in the bacterial flora, or is some other effect on the meibomian gland secretions responsible?
Blepharitis probably constitutes at least two broader categories of inflammatory lid disease, anterior and posterior blepharitis. Anterior blepharitis characterized by flaking, cuffing and scurf on the eyelashes and just anterior to the eyelashes is effectively treated with our most traditional methods: mechanical treatment and a bland antibiotic ointment. Patients suspected of having Demodex mites will benefit from adding tea tree oil (Cliradex, Bio-Tissue, among others). On the other hand, posterior blepharitis, or meibomian gland disease, typically requires something different. Gary Foulks, MD, has shown in multiple publications that the meibum in these patients is abnormal. Using gas chromatography, he demonstrated that there is a change in the carbon chain structure of the lipids in the secretion, which leads to an increase in the melting point of the meibum.
Enter the scientists at Inspire and other researchers, who determined that much of the inflammatory change in meibomian gland secretions was mediated by the cytokine pathway, specifically MMP-9. Azithromycin has an interesting anti-inflammatory effect in this same pathway. When carried in the proprietary vehicle Dura Site, AzaSite has a rapid uptake, high tissue concentration and long duration of action in meibomian glands, which makes it the perfect blepharitis drug. One problem: AzaSite is only approved for the treatment of bacterial conjunctivitis. Who can forget the introduction of “Metal Man” and “Metal Woman” at the American Academy of Ophthalmology meeting to bring attention to the amazing beneficial effect of AzaSite on blepharitis, meibomian gland disease and evaporative DES?
This brings us to our present-day treatment paradigm for blepharitis. Pretty much every patient with either anterior or posterior blepharitis will still benefit from your grandmother’s wisdom by instituting some sort of heat therapy (dry or wet) and meticulous lid hygiene. As I have written previously, the majority of posterior blepharitis patients have a nutritional imbalance that should be addressed by taking supplemental omega-3 fatty acids in highly purified fish oil. At SkyVision, we strongly favor treating localized ocular disease with localized medication whenever possible, so we add AzaSite if conservative treatment is insufficient: one drop either on the eye or massaged into the lid margin at bedtime for 2 weeks, then decreased to every other night until follow-up exam. Many patients will do well with a twice-a-week regimen; those whose condition is controlled with once-a-week therapy probably do not need the medication. This is an elegant and effective regimen, but beware that it is likely not inexpensive, so be prepared.
AzaSite has been tossed around between companies more often than a football on a Cal Berkeley kick return. Here’s hoping it has found a supportive home so that we can continue to explore its use in treating blepharitis and evaporative DES.