CEDARS/ASPENS Debates

What is the best way to treat dry eyes and ocular surface disease?

Options can range from simple techniques to the latest innovations.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

With all of the attention being paid to dry eyes and ocular surface disease, from new treatment algorithms to new diagnostic and treatment devices, there is still great debate as to the best way to treat these patients. Some prefer to keep it simple, while others prefer to take advantage of all of the latest innovations. This month, Matthew B. Goren, MD, FACS, discusses his “less is more” technique for managing lid margin disease. Kendall E. Donaldson, MD, MS, Cathleen M. McCabe, MD, Audrey R. Talley Rostov, MD, and Alice T. Epitropoulos, MD, FACS, discuss how they choose to rely on some of the latest innovations. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Simple treatment may be best for blepharitis patients

Matthew B. Goren

Every resident and medical student rotating through an ophthalmology clinic is taught to treat blepharitis by the application of “lid scrubs.” We are taught the “monologue” to inform patients of the proper use of baby shampoo, carefully scrubbing the bases of the eyelashes with Q-tips soaked in the dilute soapy solution, and that this treatment will alleviate their annoying symptoms. Trouble is, as I have learned over 25 years, it does not work. In fact, it usually makes things worse.

This column is not the place to discuss the various forms of “blepharitis” and the pathophysiology of those conditions — this topic has been exhaustively covered. Nor is it the place to discuss the various treatments of evaporative dry eye and related conditions. So I will make the assumption in this discussion that the forms of blepharitis being considered here are appropriate for treatment with “lid hygiene.” And I will concede that “lid hygiene” is, indeed, a very effective treatment for these conditions. But what is better than lid scrubs is the simple application of bland warm compresses.

It is true that the treatment of hygiene-amenable lid disease is partially aimed at removing debris from the eyelash/lid margin/meibomian gland complex. But what invariably happens when lid scrubs are recommended is a cycle of patient exuberance that leads to increased inflammation of the meibomian orifices with resultant worsening of the quality of the tear film and worsening of symptoms.

Blepharitis is one of the most irritating eye conditions for both patients as well as their treating physicians. Patients love having “something to do” to help themselves. I have found that patients will frequently “overdose” on the lid scrubs, and the results are predictable — worsening disease.

So what to do? I have found that patients who would normally be instructed to use lid scrubs are better served using simple bland warm compresses. Five minutes of soaking the closed eyes with a wash cloth saturated with water the temperature of a good hot shower (I tell patients to do it in the shower) once a day is all that is necessary. It makes patients feel better while they are doing it, which aids compliance, and over several weeks their symptoms improve to the point where maintenance can be accomplished with the treatments just a couple of times a week. Patients are almost universally relieved at no longer needing to go through the machinations of carefully shampooing their eyes.

When performed this way, simple warm compresses remove debris from the lid margin and lashes, and the heat expands the meibomian orifices and thins the glandular secretions, which creates a more regular tear film and alleviates symptoms. The result is happy patients whose symptoms are improved, and their lives are less complicated.

Many patients treated this way will still require some of the litany of other medications we routinely use for lid margin disease, such as topical steroids, tear replacements and systemic tetracyclines. However, simply replacing the old-fashioned baby shampoo treatments with a wet, warm washcloth will go a long way toward improving the quality of life of these frustrated (and frustrating) patients. Indeed, sometimes simple really is better.

Disclosure: Goren reports no relevant financial disclosures.

Proper lid hygiene forms basis of treatment for chronic blepharitis and evaporative dry eye

There has been an evolution in the treatment of “dry eye syndrome,” which began in 2012 with Lemp and colleagues revealing that 86% of patients with dry eye syndrome actually suffer from some degree of evaporative dry eye characterized by meibomian gland dysfunction. Since that time, we have witnessed an explosion in the dry eye industry including a variety of lid cleansing products (ranging from baby shampoo to hypochlorous acid preparations to tea tree oil derivatives) and devices to apply heat to the lids for cleansing and evacuation of the meibomian glands.

Kendall E. Donaldson
Cathleen M. McCabe
Audrey R. Talley Rostov
Alice T. Epitropoulos

Many of us have even created a dry eye “center of excellence” that focuses on such treatments, attracting chronically suffering patients who often desperately travel long distances to shed light on their condition. Many of our treatments are focused on the reduction of inflammation of the eyelid margin and the surface of the eye. Treatment options range from a variety of anti-inflammatory drops, pills and ointments to cleansers focused on debulking the bacterial lid flora to procedures such as exfoliation of debris from the lid margin (BlephEx, RySurg), and manual expression and thermal pulsation (LipiFlow, TearScience/Johnson & Johnson Vision) designed to evacuate the meibomian glands.

Additionally, in preparation for surgery, we routinely cleanse the lids and ocular surface with betadine with hopes of reducing the incidence of rare but potentially devastating infection manifesting as endophthalmitis. In many cases, patients with chronic lid inflammation are also pretreated with lid scrubs in an effort to reduce the bacterial flora by managing blepharitis. In fact, we now pretreat a majority of our patients to optimize the ocular surface before proceeding with cataract surgery in order to improve the accuracy of lens calculations and to increase patient comfort throughout the surgical process.

Figure 1. Crusting along the lid margin characterized by the classic findings of Demodex folliculorum.

Source: Kendall E. Donaldson, MD, MS

Figure 2. A Demodex organism crawling along an eyelash.

The heat and cleansing process associated with warm compresses and lid scrubs functions to remove superficial environmental debris from the lids, including make-up and dirt that clog the glands. The lid cleansers that function alongside warm compresses aim to reduce the excessive microbial bioburden, decreasing inflammatory bacterial toxins thus decreasing the body’s inflammatory response. Microblepharoexfoliation (BlephEx) uses a medical grade microsponge to exfoliate and remove bacteria, debris and biofilm from the lids and lashes. In our practice, we have used a variety of products but primarily treat with Avenova (NovaBay), which contains hypochlorous acid. Pure hypochlorous acid is released from our neutrophils and is a natural part of the body’s immune response, functioning to kill microorganisms and neutralize inflammatory toxins released from pathogens, reducing biofilm formation. Hypochlor (Ocusoft) is another excellent product that has been shown to be effective in lid hygiene management.

Blackie and colleagues published their results on the effectiveness of warm compresses, measuring the temperature on the outer lid vs. the inner lid. External heat application must transfer through the muscle and tarsal plate to reach the gland. Using warm compresses and changing every 2 minutes for 30 minutes, they found the upper outer lid reaches 40°C (104°F) in about 2 minutes whereas the inner lid takes 7 to 10 minutes to get to 40°C, which is the temperature required to unclog the meibomian glands. These data suggest that warm compresses are more effective when the temperature reaches 45°C (113°F) and are frequently reheated. Furthermore, it is thought that warm compresses and lid scrubs may be more efficacious after the underlying obstruction to the glands has been addressed.

In addition to education and demonstration of proper technique for lid hygiene, we also remove an eyelash for Demodex evaluation when the clinical appearance is suspicious for infection. Clearly, Demodex has always been with us; however, we were never fully acknowledging its role in patients’ symptoms until recently. Demodex is ubiquitous and becomes more prevalent with age, ranging from detection in 13% of the 3- to 15-year-old age group and progressively increasing to an incidence of 95% in the 71- to 96-year-old age group. Although most of us have only a few such organisms on our lashes and often remain asymptomatic, when there is an overpopulation of Demodex, patients experience itching, erythema and edema of the lids and eyes, foreign body sensation, crusting on the lashes, photophobia, and unstable or blurry vision. Interestingly, this increased awareness is likely attributed to industry involvement, with products such as Cliradex (Bio-Tissue) and Avenova on the market to treat this semi-chronic condition.

Lid cleansers are an ideal solution for the management of chronic blepharitis and evaporative dry eye. They are a nice adjunct to control lid inflammation in preparation for ocular surgery, and they are an essential part of treatment for Demodex, which is now being diagnosed more frequently as the underlying cause of chronic lid inflammation.

Disclosures: Donaldson reports she has financial disclosures for Alcon, Allergan, Johnson & Johnson, Bausch + Lomb, Sun, Shire, NovaBay, Omeros, TearLab and TearScience. Epitropoulos reports she receives grant/research support from Bausch + Lomb, Kala Pharmaceuticals, Ocular Therapeutix, TearLab and PRN; is a consultant/speaker for Alcon, Allergan, AMO, Bausch + Lomb, BlephEx, NovaBay, Omeros, Physician Recommended Nutriceuticals, RPS, Shire Pharmaceuticals, Sun, TearLab and TearScience; and has property rights/patent holder for EpiGlare tester. McCabe reports she is a consultant for Bausch + Lomb, Alcon, Omeros, Glaukos, Ivantis, Shire, Sun Ophthalmic and RVO. Talley Rostov reports she receives consulting fees from Allergan, Bausch + Lomb, Omeros, Shire and Sun Pharmaceutical; is on the speakers bureau for Allergan, Bausch + Lomb and Shire; and does contracted research for Ocular Therapeutix.

Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

With all of the attention being paid to dry eyes and ocular surface disease, from new treatment algorithms to new diagnostic and treatment devices, there is still great debate as to the best way to treat these patients. Some prefer to keep it simple, while others prefer to take advantage of all of the latest innovations. This month, Matthew B. Goren, MD, FACS, discusses his “less is more” technique for managing lid margin disease. Kendall E. Donaldson, MD, MS, Cathleen M. McCabe, MD, Audrey R. Talley Rostov, MD, and Alice T. Epitropoulos, MD, FACS, discuss how they choose to rely on some of the latest innovations. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Simple treatment may be best for blepharitis patients

Matthew B. Goren

Every resident and medical student rotating through an ophthalmology clinic is taught to treat blepharitis by the application of “lid scrubs.” We are taught the “monologue” to inform patients of the proper use of baby shampoo, carefully scrubbing the bases of the eyelashes with Q-tips soaked in the dilute soapy solution, and that this treatment will alleviate their annoying symptoms. Trouble is, as I have learned over 25 years, it does not work. In fact, it usually makes things worse.

This column is not the place to discuss the various forms of “blepharitis” and the pathophysiology of those conditions — this topic has been exhaustively covered. Nor is it the place to discuss the various treatments of evaporative dry eye and related conditions. So I will make the assumption in this discussion that the forms of blepharitis being considered here are appropriate for treatment with “lid hygiene.” And I will concede that “lid hygiene” is, indeed, a very effective treatment for these conditions. But what is better than lid scrubs is the simple application of bland warm compresses.

It is true that the treatment of hygiene-amenable lid disease is partially aimed at removing debris from the eyelash/lid margin/meibomian gland complex. But what invariably happens when lid scrubs are recommended is a cycle of patient exuberance that leads to increased inflammation of the meibomian orifices with resultant worsening of the quality of the tear film and worsening of symptoms.

Blepharitis is one of the most irritating eye conditions for both patients as well as their treating physicians. Patients love having “something to do” to help themselves. I have found that patients will frequently “overdose” on the lid scrubs, and the results are predictable — worsening disease.

PAGE BREAK

So what to do? I have found that patients who would normally be instructed to use lid scrubs are better served using simple bland warm compresses. Five minutes of soaking the closed eyes with a wash cloth saturated with water the temperature of a good hot shower (I tell patients to do it in the shower) once a day is all that is necessary. It makes patients feel better while they are doing it, which aids compliance, and over several weeks their symptoms improve to the point where maintenance can be accomplished with the treatments just a couple of times a week. Patients are almost universally relieved at no longer needing to go through the machinations of carefully shampooing their eyes.

When performed this way, simple warm compresses remove debris from the lid margin and lashes, and the heat expands the meibomian orifices and thins the glandular secretions, which creates a more regular tear film and alleviates symptoms. The result is happy patients whose symptoms are improved, and their lives are less complicated.

Many patients treated this way will still require some of the litany of other medications we routinely use for lid margin disease, such as topical steroids, tear replacements and systemic tetracyclines. However, simply replacing the old-fashioned baby shampoo treatments with a wet, warm washcloth will go a long way toward improving the quality of life of these frustrated (and frustrating) patients. Indeed, sometimes simple really is better.

Disclosure: Goren reports no relevant financial disclosures.

PAGE BREAK

Proper lid hygiene forms basis of treatment for chronic blepharitis and evaporative dry eye

There has been an evolution in the treatment of “dry eye syndrome,” which began in 2012 with Lemp and colleagues revealing that 86% of patients with dry eye syndrome actually suffer from some degree of evaporative dry eye characterized by meibomian gland dysfunction. Since that time, we have witnessed an explosion in the dry eye industry including a variety of lid cleansing products (ranging from baby shampoo to hypochlorous acid preparations to tea tree oil derivatives) and devices to apply heat to the lids for cleansing and evacuation of the meibomian glands.

Kendall E. Donaldson
Cathleen M. McCabe
Audrey R. Talley Rostov
Alice T. Epitropoulos

Many of us have even created a dry eye “center of excellence” that focuses on such treatments, attracting chronically suffering patients who often desperately travel long distances to shed light on their condition. Many of our treatments are focused on the reduction of inflammation of the eyelid margin and the surface of the eye. Treatment options range from a variety of anti-inflammatory drops, pills and ointments to cleansers focused on debulking the bacterial lid flora to procedures such as exfoliation of debris from the lid margin (BlephEx, RySurg), and manual expression and thermal pulsation (LipiFlow, TearScience/Johnson & Johnson Vision) designed to evacuate the meibomian glands.

Additionally, in preparation for surgery, we routinely cleanse the lids and ocular surface with betadine with hopes of reducing the incidence of rare but potentially devastating infection manifesting as endophthalmitis. In many cases, patients with chronic lid inflammation are also pretreated with lid scrubs in an effort to reduce the bacterial flora by managing blepharitis. In fact, we now pretreat a majority of our patients to optimize the ocular surface before proceeding with cataract surgery in order to improve the accuracy of lens calculations and to increase patient comfort throughout the surgical process.

Figure 1. Crusting along the lid margin characterized by the classic findings of Demodex folliculorum.

Source: Kendall E. Donaldson, MD, MS

Figure 2. A Demodex organism crawling along an eyelash.

The heat and cleansing process associated with warm compresses and lid scrubs functions to remove superficial environmental debris from the lids, including make-up and dirt that clog the glands. The lid cleansers that function alongside warm compresses aim to reduce the excessive microbial bioburden, decreasing inflammatory bacterial toxins thus decreasing the body’s inflammatory response. Microblepharoexfoliation (BlephEx) uses a medical grade microsponge to exfoliate and remove bacteria, debris and biofilm from the lids and lashes. In our practice, we have used a variety of products but primarily treat with Avenova (NovaBay), which contains hypochlorous acid. Pure hypochlorous acid is released from our neutrophils and is a natural part of the body’s immune response, functioning to kill microorganisms and neutralize inflammatory toxins released from pathogens, reducing biofilm formation. Hypochlor (Ocusoft) is another excellent product that has been shown to be effective in lid hygiene management.

Blackie and colleagues published their results on the effectiveness of warm compresses, measuring the temperature on the outer lid vs. the inner lid. External heat application must transfer through the muscle and tarsal plate to reach the gland. Using warm compresses and changing every 2 minutes for 30 minutes, they found the upper outer lid reaches 40°C (104°F) in about 2 minutes whereas the inner lid takes 7 to 10 minutes to get to 40°C, which is the temperature required to unclog the meibomian glands. These data suggest that warm compresses are more effective when the temperature reaches 45°C (113°F) and are frequently reheated. Furthermore, it is thought that warm compresses and lid scrubs may be more efficacious after the underlying obstruction to the glands has been addressed.

PAGE BREAK

In addition to education and demonstration of proper technique for lid hygiene, we also remove an eyelash for Demodex evaluation when the clinical appearance is suspicious for infection. Clearly, Demodex has always been with us; however, we were never fully acknowledging its role in patients’ symptoms until recently. Demodex is ubiquitous and becomes more prevalent with age, ranging from detection in 13% of the 3- to 15-year-old age group and progressively increasing to an incidence of 95% in the 71- to 96-year-old age group. Although most of us have only a few such organisms on our lashes and often remain asymptomatic, when there is an overpopulation of Demodex, patients experience itching, erythema and edema of the lids and eyes, foreign body sensation, crusting on the lashes, photophobia, and unstable or blurry vision. Interestingly, this increased awareness is likely attributed to industry involvement, with products such as Cliradex (Bio-Tissue) and Avenova on the market to treat this semi-chronic condition.

Lid cleansers are an ideal solution for the management of chronic blepharitis and evaporative dry eye. They are a nice adjunct to control lid inflammation in preparation for ocular surgery, and they are an essential part of treatment for Demodex, which is now being diagnosed more frequently as the underlying cause of chronic lid inflammation.

Disclosures: Donaldson reports she has financial disclosures for Alcon, Allergan, Johnson & Johnson, Bausch + Lomb, Sun, Shire, NovaBay, Omeros, TearLab and TearScience. Epitropoulos reports she receives grant/research support from Bausch + Lomb, Kala Pharmaceuticals, Ocular Therapeutix, TearLab and PRN; is a consultant/speaker for Alcon, Allergan, AMO, Bausch + Lomb, BlephEx, NovaBay, Omeros, Physician Recommended Nutriceuticals, RPS, Shire Pharmaceuticals, Sun, TearLab and TearScience; and has property rights/patent holder for EpiGlare tester. McCabe reports she is a consultant for Bausch + Lomb, Alcon, Omeros, Glaukos, Ivantis, Shire, Sun Ophthalmic and RVO. Talley Rostov reports she receives consulting fees from Allergan, Bausch + Lomb, Omeros, Shire and Sun Pharmaceutical; is on the speakers bureau for Allergan, Bausch + Lomb and Shire; and does contracted research for Ocular Therapeutix.