In-office treatment provides targeted approach to blepharitis

Blepharitis is one of the most common eye conditions seen by ophthalmologists, with the overall prevalence in the United States approaching 50%. The primary risk factors for the condition appear to be age and poor lid hygiene. Because the eyelid is one of the few body parts that rarely receives a thorough cleansing, staphylococcal biofilm accumulates along the lid margins over time. Whether these bacteria originate on the lids or migrate up from the nasal cavity early in life remains unknown, but we do know that they tend to increase with age. This may partly explain why concurrent ocular surface disorders such as meibomian gland dysfunction and dry eye also tend to increase with age.

James M. Rynerson

Despite its prevalence, blepharitis is largely ignored by clinicians because few treatments offer the potential for true success. Artificial tears and lid cleansing regimens may occasionally be prescribed, but such treatment is rarely effective. Patients are often reluctant or incapable of performing lid scrubs with the necessary force and in the appropriate location to affect biofilms in a meaningful way. Ideally, treatment for blepharitis should consist of an in-office therapy, performed at the time of diagnosis, and provide a mechanism to remove the inflammatory exotoxin-laden biofilm and avert progression to more severe forms of ocular surface disease.

Mechanical debridement of the lid margin using a spud or spatula has been advocated in the treatment of meibomian gland dysfunction, and this technique may be helpful in removing biofilm to some degree. Unfortunately, this procedure can potentially induce microtrauma to the lid margin, allowing bacterial pathogens direct access to the underlying tissue. Moreover, scraping is inefficient and leaves behind residual bacteria, which allows the biofilm to re-establish itself quickly and easily.

New technique

The BlephEx device is held like a pen and the rotating tip is applied to the base of the eyelashes.

Image: Rynerson JM

Microblepharoexfoliation (MBE) is a new technique for removing biofilm from the eyelid margin. It is an in-office procedure performed by the doctor using a patented instrument called BlephEx (BlephEx LLC), a handheld device that rotates a PVA sponge soaked in a commercial eyelid cleaning solution. Via MBE, the lid margins are debrided and exfoliated, and the meibomian glands are unroofed. With the sponge tip rotating at approximately 2,000 RPM, the biofilm and exotoxins are removed, and bacterial overload is debulked. The procedure also likely reduces the population of bacteria to below the quorum-sensing numbers that induce virulence factor production.

MBE is easy to learn and can be mastered after one or two procedures. The BlephEx device may be used with either hand and is held like a pen, cradled between the index finger and thumb. After soaking the disposable sponge tip in cleaning solution, the rotating head is applied to the base of the lashes with firm pressure, moving along the lid margin in small increments for 20 to 30 seconds. After the first pass, the rotation of the sponge tip is reversed and the lid margin is re-treated in a retrograde fashion, being sure to cover not only the lashes but also the lid margin back to the mucocutaneous junction. Both upper and lower lids are treated in a similar fashion, and a new tip is utilized for each eyelid to ensure elimination and disposal of accumulated bacteria. Although the treatment is painless, many patients describe a tickling sensation due to the vibration of the rotating tip; for this reason, it is recommended to use a drop or two of 0.5% tetracaine before the procedure. After the lids have been thoroughly cleaned, the excess surfactant is lavaged from the eye using balanced salt solution or sterile eye wash.

Home lid scrub therapy can and should be employed after MBE, but because this does not offer the same efficacy as BlephEx, biofilm will re-accumulate over time. The patient should understand that even in the absence of symptoms, low-grade inflammation can cause a slow disruption of the normal lid and tear film anatomy. Thus, repeat MBE treatments are important and should be performed every 3 to 6 months.

References:
Biofilm bacteria. The Marshall Protocol Knowledge Base. http://mpkb.org/home/pathogenesis/microbiota/biofilm. Updated Feb. 14, 2014. Accessed Oct. 21, 2014.
Chotikavanich S, et al. Invest Ophthalmol Vis Sci. 2009;doi:10.1167/iovs.08-2476.
Høiby N, et al. Int J Antimicrob Agents. 2010;doi:10.1016/j.ijantimicag.2009.12.011.
Hou W, et al. Invest Ophthalmol Vis Sci. 2012;doi:10.1167/iovs.11-9114.
Korb DR, et al. Cornea. 2013;doi:10.1097/ICO.0b013e3182a73843.
Lemp MA, et al. Ocul Surf. 2009;doi:10.1016/S1542-0124(12)70620-1.

For more information:
James M. Rynerson, MD, can be reached at BlephEx LLC, 2290 10th Ave. North, Lake Worth, FL 33461; 800-257-9787; email: drr@rysurg.com.
Disclosure: Rynerson has a financial interest in BlephEx and is the president and CEO of BlephEx LLC. 

Blepharitis is one of the most common eye conditions seen by ophthalmologists, with the overall prevalence in the United States approaching 50%. The primary risk factors for the condition appear to be age and poor lid hygiene. Because the eyelid is one of the few body parts that rarely receives a thorough cleansing, staphylococcal biofilm accumulates along the lid margins over time. Whether these bacteria originate on the lids or migrate up from the nasal cavity early in life remains unknown, but we do know that they tend to increase with age. This may partly explain why concurrent ocular surface disorders such as meibomian gland dysfunction and dry eye also tend to increase with age.

James M. Rynerson

Despite its prevalence, blepharitis is largely ignored by clinicians because few treatments offer the potential for true success. Artificial tears and lid cleansing regimens may occasionally be prescribed, but such treatment is rarely effective. Patients are often reluctant or incapable of performing lid scrubs with the necessary force and in the appropriate location to affect biofilms in a meaningful way. Ideally, treatment for blepharitis should consist of an in-office therapy, performed at the time of diagnosis, and provide a mechanism to remove the inflammatory exotoxin-laden biofilm and avert progression to more severe forms of ocular surface disease.

Mechanical debridement of the lid margin using a spud or spatula has been advocated in the treatment of meibomian gland dysfunction, and this technique may be helpful in removing biofilm to some degree. Unfortunately, this procedure can potentially induce microtrauma to the lid margin, allowing bacterial pathogens direct access to the underlying tissue. Moreover, scraping is inefficient and leaves behind residual bacteria, which allows the biofilm to re-establish itself quickly and easily.

New technique

The BlephEx device is held like a pen and the rotating tip is applied to the base of the eyelashes.

Image: Rynerson JM

Microblepharoexfoliation (MBE) is a new technique for removing biofilm from the eyelid margin. It is an in-office procedure performed by the doctor using a patented instrument called BlephEx (BlephEx LLC), a handheld device that rotates a PVA sponge soaked in a commercial eyelid cleaning solution. Via MBE, the lid margins are debrided and exfoliated, and the meibomian glands are unroofed. With the sponge tip rotating at approximately 2,000 RPM, the biofilm and exotoxins are removed, and bacterial overload is debulked. The procedure also likely reduces the population of bacteria to below the quorum-sensing numbers that induce virulence factor production.

MBE is easy to learn and can be mastered after one or two procedures. The BlephEx device may be used with either hand and is held like a pen, cradled between the index finger and thumb. After soaking the disposable sponge tip in cleaning solution, the rotating head is applied to the base of the lashes with firm pressure, moving along the lid margin in small increments for 20 to 30 seconds. After the first pass, the rotation of the sponge tip is reversed and the lid margin is re-treated in a retrograde fashion, being sure to cover not only the lashes but also the lid margin back to the mucocutaneous junction. Both upper and lower lids are treated in a similar fashion, and a new tip is utilized for each eyelid to ensure elimination and disposal of accumulated bacteria. Although the treatment is painless, many patients describe a tickling sensation due to the vibration of the rotating tip; for this reason, it is recommended to use a drop or two of 0.5% tetracaine before the procedure. After the lids have been thoroughly cleaned, the excess surfactant is lavaged from the eye using balanced salt solution or sterile eye wash.

Home lid scrub therapy can and should be employed after MBE, but because this does not offer the same efficacy as BlephEx, biofilm will re-accumulate over time. The patient should understand that even in the absence of symptoms, low-grade inflammation can cause a slow disruption of the normal lid and tear film anatomy. Thus, repeat MBE treatments are important and should be performed every 3 to 6 months.

References:
Biofilm bacteria. The Marshall Protocol Knowledge Base. http://mpkb.org/home/pathogenesis/microbiota/biofilm. Updated Feb. 14, 2014. Accessed Oct. 21, 2014.
Chotikavanich S, et al. Invest Ophthalmol Vis Sci. 2009;doi:10.1167/iovs.08-2476.
Høiby N, et al. Int J Antimicrob Agents. 2010;doi:10.1016/j.ijantimicag.2009.12.011.
Hou W, et al. Invest Ophthalmol Vis Sci. 2012;doi:10.1167/iovs.11-9114.
Korb DR, et al. Cornea. 2013;doi:10.1097/ICO.0b013e3182a73843.
Lemp MA, et al. Ocul Surf. 2009;doi:10.1016/S1542-0124(12)70620-1.

For more information:
James M. Rynerson, MD, can be reached at BlephEx LLC, 2290 10th Ave. North, Lake Worth, FL 33461; 800-257-9787; email: drr@rysurg.com.
Disclosure: Rynerson has a financial interest in BlephEx and is the president and CEO of BlephEx LLC.