Round Tables

Roundtable: Corneal consequences of chronic inflammation can be severe in children

Meibomian gland dysfunction is not an adults-only disease, and when the combination of inflammation of the eyelids, conjunctiva and cornea is prolonged in children, the corneal consequences and effect on vision can be severe.

This chronic inflammation, called blepharokeratoconjunctivitis, can result in corneal scarring, vascularization and opacity, which in children can cause symptoms of irritation, watering, photophobia and reduced vision.

Here, the OSN Pediatrics/Strabismus Board Members, led by Section Editor Robert S. Gold, MD, at the American Association for Pediatric Ophthalmology and Strabismus meeting in San Diego, give their insights for managing chronic anterior inflammation in their practices.

Erin D. Stahl, MD: Blepharokeratoconjunctivitis describes the lid inflammation, the conjunctival inflammation and the corneal involvement. When a patient has all three, that is when I usually see them.

Roundtable Participants

  • Robert Gold
  • Moderator

  • Robert S. Gold
  • Kenneth P. Cheng
  • Kenneth P. Cheng
  • Douglas R. Frederick
  • Douglas R. Frederick
  • Courtney L. Kraus
  • Courtney L. Kraus
  • Jordana Smith
  • Jordana M. Smith
  • Erin D. Stahl
  • Erin D. Stahl
  • Rudolph S. Wagner
  • Rudolph S. Wagner
  • Roberto Warman
  • Roberto Warman
  • M. Edward Wilson
  • M. Edward Wilson

We have screening protocols for our ophthalmologists and optometrists who treat patients with less severe disease. The protocol involves regular lid hygiene, good-quality omega-3s and warm compresses, depending on the severity of the meibomian gland dysfunction. If the patient needs topical antibiotics, systemic antibiotics or topical steroids, then I prefer they come to me to initiate that treatment.

Courtney L. Kraus, MD: Not so much in the young patients, but do you use oral antibiotics — erythromycin or azithromycin — at low dose?

Stahl: I use them if I have to. After I have tried everything else, I start oral antibiotics at 1 month of a moderate dose and then a second month of every other day dosing if needed. Then I reassess. Sometimes I only have to repeat that every year or so to get the disease under control. I tell the families that this is a cycle of disease, and antibiotics and steroids are needed to gain control. Often, patients do not get back into that cycle unless they start shying away from their daily treatment.

Roberto Warman, MD: One important thing to remember is that young children are intolerant to oral erythromycin or azithromycin. They get diarrhea. You can try it, but many times you will have to stop it. It is not a panacea. Unfortunately, AzaSite (azithromycin ophthalmic solution, Akorn) is so expensive that you can almost never use it. But I would use it first if I could.

Robert S. Gold, MD: By the time I see these patients, they are weeks or months into different treatments by their primary care physician. They have perilimbal infiltrates all over their cornea, and they are so photophobic and in so much discomfort that you almost have to do more than just one thing to treat them. As Erin said, it is a cycle. I tell the parents that this is going to take time to get better. After weeks and months of getting worse, it is not going to get better in 6 days.

Douglas R. Fredrick, MD: It is also important when you are prescribing lid hygiene to observe them do it, especially when they come in for the second and third time and say they are still getting styes. I ask them to demonstrate how they are cleaning the lids because often they are not doing it correctly. We call it “teach-back,” describing what you are going to do and then observing them do it. That can be helpful in increasing compliance to treat the lid disease.

But, to answer the question, I will use topical erythromycin liberally. I am not so worried about the development of resistance using erythromycin. Once the situation is controlled on a long-term basis, then once a week on Sunday night, they can do their maintenance hygiene. Also, like Bob said, I tell them that it will take a long time for this condition to burn out. And it usually does with time.

Warman: When the case is a serious cornea problem, I do not hesitate to put them on topical steroids. I prefer a generic of Maxitrol (neomycin, polymyxin B sulfate, dexamethasone ophthalmic suspension, Alcon). I have no problem hitting them strongly with the steroid, seeing them often at the beginning of treatment and watching the pressure, and doing what we need to do because the consequences are worse.

Kenneth P. Cheng, MD: I was at a meeting where somebody was talking about manually expressing the meibomian glands, almost like LipiFlow (Johnson & Johnson Vision) but without the heat. First, I will say that there are few children who are going to let you do that. That said, I did have a 6-year-old who just had the worst disease that was not getting any better. After we built a rapport, I was able to squeeze the glands with Q-tips and she did get significantly better. I think the glands were just so clogged up that it helped. It probably has a limited application in children, but I did find it helpful.

Rudolph S. Wagner, MD: Frequently when you take children with chalazia to the OR for surgical excision, you will observe oily obstructing “plugs” within the meibomian gland openings along the lid margin. I will express the obstructions by applying pressure to the lid margins while under anesthesia.

There is a subset of older children that have a type of rosacea that will respond to low-dose oral minocycline, in addition to the other methods that we are using to treat them.

Stahl: It is not uncommon for me to take a patient to the OR who does not have chalazia just to clean out all their meibomian glands. I find about one patient a year who has true occlusive meibomian gland disease with not one single open gland. I will probe every one of their meibomian glands, and they have crystal clear oils in them, no bacteria, no turbidity. They just do not make any oils. It is one of those things that you do not even consider. I squeeze the glands at the slit lamp for everybody who can tolerate it, but there are certain ones who truly have a cap on every gland and nothing ever comes out. Once you probe them, their problem goes away.

Gold: Do you ever take them to the OR to do a LipiFlow or BlephEx (BlephEx) treatment? Part of our practice is a large adult practice, and I can tell you that it really works well.

Stahl: Essentially, I just do it manually.

Cheng: Does anybody culture these patients?

Jordana M. Smith, MD: It is actually easy to do in clinic with topical anesthetic. If you are specifically concerned about MRSA, there is an easy screening test that is not expensive. I do not hesitate to obtain a culture, especially if they are not responding.

Another thing, getting back to topical antibiotics, is that we have no erythromycin ointment in Arizona at all. So, I tend to start with tobramycin or just go straight to the generic Maxitrol ointment.

M. Edward Wilson, MD: I think the milder disease, meibomian gland dysfunction, is underdiagnosed in pediatric ophthalmology practices, and it presents in sometimes unusual ways. The common one I think of is blinking. The parent wonders if it is a nervous tic or an anxious habit because they are blinking and rolling their eyes. If you look at the slit lamp and they have mounds of oil there and they have lid changes, that is the cause of the blinking because their tears are evaporating, and they do not have a good oil coat.

Disclosures: Fredrick reports he is an uncompensated member of the scientific advisory board of Eyenovia. Stahl reports she is a consultant for Treehouse Health and a consultant for and shareholder in Nevakar. The other roundtable participants report no relevant financial disclosures.

Meibomian gland dysfunction is not an adults-only disease, and when the combination of inflammation of the eyelids, conjunctiva and cornea is prolonged in children, the corneal consequences and effect on vision can be severe.

This chronic inflammation, called blepharokeratoconjunctivitis, can result in corneal scarring, vascularization and opacity, which in children can cause symptoms of irritation, watering, photophobia and reduced vision.

Here, the OSN Pediatrics/Strabismus Board Members, led by Section Editor Robert S. Gold, MD, at the American Association for Pediatric Ophthalmology and Strabismus meeting in San Diego, give their insights for managing chronic anterior inflammation in their practices.

Erin D. Stahl, MD: Blepharokeratoconjunctivitis describes the lid inflammation, the conjunctival inflammation and the corneal involvement. When a patient has all three, that is when I usually see them.

Roundtable Participants

  • Robert Gold
  • Moderator

  • Robert S. Gold
  • Kenneth P. Cheng
  • Kenneth P. Cheng
  • Douglas R. Frederick
  • Douglas R. Frederick
  • Courtney L. Kraus
  • Courtney L. Kraus
  • Jordana Smith
  • Jordana M. Smith
  • Erin D. Stahl
  • Erin D. Stahl
  • Rudolph S. Wagner
  • Rudolph S. Wagner
  • Roberto Warman
  • Roberto Warman
  • M. Edward Wilson
  • M. Edward Wilson

We have screening protocols for our ophthalmologists and optometrists who treat patients with less severe disease. The protocol involves regular lid hygiene, good-quality omega-3s and warm compresses, depending on the severity of the meibomian gland dysfunction. If the patient needs topical antibiotics, systemic antibiotics or topical steroids, then I prefer they come to me to initiate that treatment.

Courtney L. Kraus, MD: Not so much in the young patients, but do you use oral antibiotics — erythromycin or azithromycin — at low dose?

Stahl: I use them if I have to. After I have tried everything else, I start oral antibiotics at 1 month of a moderate dose and then a second month of every other day dosing if needed. Then I reassess. Sometimes I only have to repeat that every year or so to get the disease under control. I tell the families that this is a cycle of disease, and antibiotics and steroids are needed to gain control. Often, patients do not get back into that cycle unless they start shying away from their daily treatment.

Roberto Warman, MD: One important thing to remember is that young children are intolerant to oral erythromycin or azithromycin. They get diarrhea. You can try it, but many times you will have to stop it. It is not a panacea. Unfortunately, AzaSite (azithromycin ophthalmic solution, Akorn) is so expensive that you can almost never use it. But I would use it first if I could.

Robert S. Gold, MD: By the time I see these patients, they are weeks or months into different treatments by their primary care physician. They have perilimbal infiltrates all over their cornea, and they are so photophobic and in so much discomfort that you almost have to do more than just one thing to treat them. As Erin said, it is a cycle. I tell the parents that this is going to take time to get better. After weeks and months of getting worse, it is not going to get better in 6 days.

PAGE BREAK

Douglas R. Fredrick, MD: It is also important when you are prescribing lid hygiene to observe them do it, especially when they come in for the second and third time and say they are still getting styes. I ask them to demonstrate how they are cleaning the lids because often they are not doing it correctly. We call it “teach-back,” describing what you are going to do and then observing them do it. That can be helpful in increasing compliance to treat the lid disease.

But, to answer the question, I will use topical erythromycin liberally. I am not so worried about the development of resistance using erythromycin. Once the situation is controlled on a long-term basis, then once a week on Sunday night, they can do their maintenance hygiene. Also, like Bob said, I tell them that it will take a long time for this condition to burn out. And it usually does with time.

Warman: When the case is a serious cornea problem, I do not hesitate to put them on topical steroids. I prefer a generic of Maxitrol (neomycin, polymyxin B sulfate, dexamethasone ophthalmic suspension, Alcon). I have no problem hitting them strongly with the steroid, seeing them often at the beginning of treatment and watching the pressure, and doing what we need to do because the consequences are worse.

Kenneth P. Cheng, MD: I was at a meeting where somebody was talking about manually expressing the meibomian glands, almost like LipiFlow (Johnson & Johnson Vision) but without the heat. First, I will say that there are few children who are going to let you do that. That said, I did have a 6-year-old who just had the worst disease that was not getting any better. After we built a rapport, I was able to squeeze the glands with Q-tips and she did get significantly better. I think the glands were just so clogged up that it helped. It probably has a limited application in children, but I did find it helpful.

Rudolph S. Wagner, MD: Frequently when you take children with chalazia to the OR for surgical excision, you will observe oily obstructing “plugs” within the meibomian gland openings along the lid margin. I will express the obstructions by applying pressure to the lid margins while under anesthesia.

There is a subset of older children that have a type of rosacea that will respond to low-dose oral minocycline, in addition to the other methods that we are using to treat them.

PAGE BREAK

Stahl: It is not uncommon for me to take a patient to the OR who does not have chalazia just to clean out all their meibomian glands. I find about one patient a year who has true occlusive meibomian gland disease with not one single open gland. I will probe every one of their meibomian glands, and they have crystal clear oils in them, no bacteria, no turbidity. They just do not make any oils. It is one of those things that you do not even consider. I squeeze the glands at the slit lamp for everybody who can tolerate it, but there are certain ones who truly have a cap on every gland and nothing ever comes out. Once you probe them, their problem goes away.

Gold: Do you ever take them to the OR to do a LipiFlow or BlephEx (BlephEx) treatment? Part of our practice is a large adult practice, and I can tell you that it really works well.

Stahl: Essentially, I just do it manually.

Cheng: Does anybody culture these patients?

Jordana M. Smith, MD: It is actually easy to do in clinic with topical anesthetic. If you are specifically concerned about MRSA, there is an easy screening test that is not expensive. I do not hesitate to obtain a culture, especially if they are not responding.

Another thing, getting back to topical antibiotics, is that we have no erythromycin ointment in Arizona at all. So, I tend to start with tobramycin or just go straight to the generic Maxitrol ointment.

M. Edward Wilson, MD: I think the milder disease, meibomian gland dysfunction, is underdiagnosed in pediatric ophthalmology practices, and it presents in sometimes unusual ways. The common one I think of is blinking. The parent wonders if it is a nervous tic or an anxious habit because they are blinking and rolling their eyes. If you look at the slit lamp and they have mounds of oil there and they have lid changes, that is the cause of the blinking because their tears are evaporating, and they do not have a good oil coat.

Disclosures: Fredrick reports he is an uncompensated member of the scientific advisory board of Eyenovia. Stahl reports she is a consultant for Treehouse Health and a consultant for and shareholder in Nevakar. The other roundtable participants report no relevant financial disclosures.