Cool approach to managing hot lids

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CET CONTINUING Sponsored by 1 CET POINT Cool approach to managing hot lids Amit Patel, MB BCh, FRCOphth Eyelid inflammation is a common condition encountered in both primary and secondary care, and

1 CET CONTINUING Sponsored by 1 CET POINT Cool approach to managing hot lids Amit Patel, MB BCh, FRCOphth Eyelid inflammation is a common condition encountered in both primary and secondary care, and encompasses lid margin disease (commonly referred to as blepharitis), blockage and infection of the oil glands or lash follicles. The eyelid anatomy is complex and consists of skin, muscle, mucous membrane, glands and lash follicles. Each of these components play a crucial part in protecting the eyeball from the environment, ensuring that its surface remains moist and optically clear. Therefore, any inflammation of the eyelids may compromise this protection and lead to contiguous inflammation or injury to the adjacent conjunctiva and cornea. Within primary care, optometrists are best placed to recognise, treat and monitor eyelid inflammation. Accurate diagnosis, classification and recognition of the sequelae are, therefore, important in initiating the correct treatment and preventing complications, as described in this article. Course code C O/D Deadline: March 8, Learning objectives (Group 6, 6.1.4) Be able to examine and identify external ocular pathology giving correct advice on treatment and having awareness of pharmaceutical agents (Group 6, 6.1.5) Be able to recognise common anterior eye disorders using appropriate techniques and manage appropriately including referral when needed Learning objectives (Group 8, 8.1.1) Be able to identify common diseases of the external eye including signs and symptoms (Group 8, 8.1.3) Understand the clinical treatment of a range of significant anterior eye ocular diseases and disorders About the author Amit Patel is a consultant ophthalmologist at the Heart of England NHS Trust and Midland Eye Institute in Birmingham. He has a special interest in corneal, cataract and refractive surgery. He is a treasurer of the BSRS and a council member of the Medical Contact Lens and Ocular Surface Association. Visit for all the information about Enhanced CET requirements

1 CET POINT CET CONTINUING Blepharitis Blepharitis represents inflammation of the eyelid margin and is an extremely common, chronic condition which usually has a long and protracted course.

Furthermore, the severity of symptoms may not coincide with the degree of visible inflammation.

2 1 CET POINT CET CONTINUING Blepharitis Blepharitis represents inflammation of the eyelid margin and is an extremely common, chronic condition which usually has a long and protracted course. It may, however, present acutely and tends to affect all ages. Symptoms 48 include redness, itching, burning, crusting, discharge and fluctuating vision. Furthermore, the severity of symptoms may not coincide with the degree of visible inflammation. Patients may be frustrated with previous treatment advice and intolerant to over-the-counter (OTC) medications. The associated tear film abnormality usually means that they are Figure 1 Anterior blepharitis with obliteration of the meibomian gland orifices. Courtesy of Professor Michael Doughty, Glasgow Caledonian University Figure 2 Severe posterior blepharitis with prominent vessels (telangiectasia) and oil capping of the meibomian glands evident on the upper eyelid frequently intolerant to contact lenses and may also have numerous glasses and complain that none are right. Thus the chronic nature, variability of symptoms, and a lack of a cure poses a great challenge and results in frustration for both patients and eye care professionals. have seborrhoea elsewhere on the body. Both male and female preponderance is equal. Greasy flakes or scales are seen around the base of the eyelashes in addition to mild redness of the lid margin. Both seborrhoeic and staphylococcal foam in the tear film and the meibomian gland ductules are dilated and easily expressed (Figure 2). Inflammation of the meibomian glands (meibomitis) may result in inspissated secretions, which are difficult to express and thus lead to obstruction of the glands. Classification Various classifications and sub-classifications of blepharitis have emerged over the years. 1,2,3 For sake of simplicity, it is generally divided into two groups, although, in reality, patients frequently have a combination of the various subtypes and other associated conditions (see below). Accurate sub-type classification for each patient is not always necessary, as the treatment choices do not alter. However, it is important to recognise the different characteristics of each type. Anterior blepharitis This is commonly caused by bacteria (staphylococcal blepharitis) or dandruff of the scalp and eyebrows (seborrhoeic blepharitis). Staphylococcal blepharitis occurs more commonly in young women and has a waxing and waning course. It is characterised by lid blepharitis may coexist. Furthermore, there can be obliteration of the meibomian gland orifices (Figure 1). In recent years, parasitic infestation of the eyelashes by Demodex has been implicated as a cause of anterior blepharitis. 4,5 The mites typically cause cylindrical crusting around the base of the eyelashes. Suspected cases may be treated effectively with scrubs containing tea tree oil. Posterior blepharitis This results from excessive or abnormal synthesis of lipids from dysfunctional meibomian glands. The lipids produced by the meibomian glands serve several important functions: Retard tear film evaporation Lower the surface tension of tears thus drawing water into the tear film Prevent contamination of the tear film by skin oils Chalazion A chalazion is a nodular cyst resulting from the blockage of a meibomian gland. The trapped sebaceous material extrudes into the adjacent tissue and incites a lipogranulomatous inflammatory reaction (Figure 3). They present as a slightly tender nodular swelling within 5mm of the lid margin and can develop insidiously or acutely. Although many chalazia resolve spontaneously, it is advisable to initiate conservative treatment at the outset (see later). Intralesional steroid injection may help to resolve the chalazia, although persistent chalazia with hardened secretions would require surgical intervention. This involves placing a clamp over the eyelid and everting it. The tarsal conjunctival surface is then incised and curettage performed to remove all the compacted secretions and inflammatory material margin redness, dilated vessels (telangiectasia), crusts and collarettes around the base of the eyelashes. Seborrhoiec blepharitis occurs in Provide a seal between the lid margins when asleep Provide a smooth optical surface. External hordeolum (stye) This is an infection of the glands of Moll, Zeiss a relatively older age group and patients may Excessive production results in collection of or lash follicles. Although it can be sterile, it

Sponsored by is frequently caused by a staphylococcal infection. It presents as an acute, painful, inflammatory nodule on the anterior aspect of the eyelid.

Associated conditions Lid margin inflammation is frequently associated with rosacea, seborrhoiec dermatitis and lacrimal insufficiency.

3 Sponsored by is frequently caused by a staphylococcal infection. It presents as an acute, painful, inflammatory nodule on the anterior aspect of the eyelid. These usually rupture and resolve spontaneously but, as with chalazia, treating the associated blepharitis may reduce the recurrence rate. Associated conditions Lid margin inflammation is frequently associated with rosacea, seborrhoiec dermatitis and lacrimal insufficiency. Rosacea is a common dermatological condition which affects the face. Typically, patients have redness (erythema) of the cheeks, nose and chin. Close inspection reveals small dilated blood vessels on the skin surface (telangiectasia). It may present at any age, but typically begins after the age of 30 years. It is common in patients with fair skin and affects women more than men. These patients might develop severe blepharokeratoconjunctivitis leading to peripheral corneal thinning and vascularisation (Figure 4). Seborrhoiec dermatitis is a common inflammatory skin condition which causes flaky, white/yellow scales on oily areas such as the scalp, inside the ear or eyelid margin. It is thought to be due to a combination of excess production of skin oil and irritation from a yeast infection (malassezia). Recognition of these skin conditions is important to direct appropriate systemic treatment and in the management of associated blepharitis. Meibomian gland dysfunction is frequently associated with aqueous deficiency dry eye. These patients may therefore have severe symptoms in the presence of relatively mild lid margin disease and it is important to exclude the presence of Sjogren s syndrome. Examination History A careful and thorough history will help the evaluation of disease severity and its impact on daily life. Complaints include redness, itching, burning, crusting, discharge, fluctuating vision and contact lens intolerance. It is useful to incorporate the use of a questionnaire, for example ocular surface disease index. 6 This not only helps to monitor treatment response, but also empowers the patient to keep track of their symptoms and perhaps aid compliance. Figure 3 Conjunctival granuloma secondary to a chalazion A note should be made of the patient s occupation, environment and general health. Details of any previous treatments which they have tried, and their compliance with these, would help formulate a treatment plan and judge the potential prognosis for improvement. Observation A general observation of the patient s eyelids, face, skin and blinking characteristics will reveal any associated dermatological conditions and help assess the severity of the disease. Slit lamp biomicroscopy A systematic examination of the skin, lashes, lid margin, gland orifices, tarsal and bulbar conjunctiva, tear film and cornea, is required. The eyelid skin may show signs of seborrhoea, eczema or rosacea. It may be thin and friable with fissures which bleed easily with minimal trauma or may be thickened due to frequent rubbing and excoriation. Lid margin inflammation disrupts the anatomy of the eyelid and might lead to misdirection of lashes, especially in chronic cases (trichiasis Figure 5), loss of lashes (madarosis) and poliosis (loss of lash pigmentation). In addition, crusts and collarettes may be seen around the base of the lashes in anterior blepharitis. The lid margin has a variable appearance depending on the sub-type of blepharitis and ranges from minimal telangiectasia to intense redness, irregularity and ulceration. There may be associated lid malpositioning and punctal ectropion. The meibomian gland orifices may be dilated and easily express secretions leading to a foamy tear film or capped with meibomian secretion. In the latter case, gentle pressure on the eyelid margin may lead to expression of inspissated secretions. The adjacent tarsal and bulbar conjunctiva may be inflamed in some cases and associated dry eyes may exacerbate this. Occasionally, small raised inflammatory lesions (phlyctens) may arise at the limbus. There is intense vascular injection around the lesions, which are common in young children and young adults. Although found mainly at the limbus, they may occur on the bulbar conjunctiva too. Repeated attacks might cause the lesion to migrate onto the central cornea. It is important to examine the ocular surface with the instillation of sodium fluorescein dye. The cornea may exhibit punctate staining and occasionally develop marginal ulcers (marginal keratitis Figure 6, page 43). These are characterised by grey-white infiltrates, which are parallel to the limbus, but are separated from it by a small clear zone of 1-2mm. The ulcers are usually located adjacent to the area where the lid margin normally traverses Figure 4 Peripheral corneal thinning and vascularistaion in a patient with a previous episode of severe rosacea blepharokeratoconjunctivitis 49

1 CET POINT CET CONTINUING 50 the cornea. Initially the corneal epithelium over the ulcer is intact, but a defect might occur later in the course of the disease.

4 1 CET POINT CET CONTINUING 50 the cornea. Initially the corneal epithelium over the ulcer is intact, but a defect might occur later in the course of the disease. Both phlyctens and marginal ulcers are thought to be caused by an immune response to the exogenous staphylococcal antigen. Tear assessment With sodium fluorescein dye instilled, the quality and stability of the tear film can be assessed by way of tear break-up time (TBUT), while tear osmolarity can provide additional useful information; the quantity of tears is assessed by measuring the tear meniscus height and by performing a Schirmers test. Details of these tests have been described previously (see OT, July 27, 2012). 7 Management Education Patient education is often overlooked and forms the most important part of management. It is important for the patient to understand the chronic and relapsing nature of the disease as well as the role of oil produced by the eyelids (that is, protect, lubricate and stop evaporation of tears). It is also useful to explain the aim of each treatment and have written information for them to take away. Time spent educating the patient will aid compliance to treatment and allows them to alter their treatment as symptoms vary. Primary care treatment This involves lid hygiene, lubricants, topical antibiotics and dietary modification. Lid hygiene forms the mainstay of treatment and patients are encouraged to make this part of their daily routine. It consists of the following steps: Hot compresses: A clean flannel dipped in hot water (not too hot so as to scald) is applied to the closed eyelids for 5-10 minutes. As the flannel cools, it should be reheated by soaking in the hot water. Commercially available heat pads, for example an eyebag, might be used to serve the same purpose. The aim of this treatment is to melt the meibomian oils which may have inspissated and to soften any crusts around the eyelash bases. It is an effective treatment for chalazia and styes and should be initiated at the onset in order to minimise the risk of persistent lumps, and hence surgical intervention. Lid massage: This may be performed using a cotton bud or fingertips. Firm pressure is applied to the eyelid and a rotary motion (upwards or downwards) towards the eyelid margin is required. The massage aims to express the melted secretions out of the meibomian glands and increase the lipid layer thickness. This in turn reduces the evaporation of underlying aqueous tears and provides symptomatic relief. Lid scrubs: A moistened cotton bud tip is used to gently scrub the base of the lashes and eyelid margin. The previous two steps will have softened the scales and debris to allow ease of removal. Care should be taken to avoid rubbing aggressively as this may exacerbate the inflammation and patients should be advised not to encroach the inner lining (palpebral conjunctiva) of the eyelids. Some practitioners advocate scrubbing the eyelids using a solution of diluted baby shampoo although the results and effectiveness of Figure 5 Chronic blepharitis leading to lid margin irregularity and trichiasis this is questionable. Commercially available lid scrubs and wipes for example Lidcare and Ocusoft may be preferable, especially in patients with poor, or limited, manual dexterity. Lubricants do not treat the underlying problem, but serve to replace the evaporated tears and wash/dilute the inflammatory broth lying on the ocular surface and lid margin. Many patients may have aqueous deficiency dry eye or Sjogren s syndrome and would benefit from regular and frequent lubricant use. A discussion of the choice of lubricants is beyond the scope of this article, but patients must be encouraged to try various types until they find one which suits them best. Patients with severe lid margin inflammation and those due to have intraocular surgery may benefit from topical antibiotic application for example chloramphenicol (available OTC in the UK) to remove the staphylococcal infection. Dietary supplementation with omega-3

Sponsored by fatty acids is beneficial in blepharitis and has been shown to improve symptoms, quality of meibomian secretions and increase the TBUT.

5 Sponsored by fatty acids is beneficial in blepharitis and has been shown to improve symptoms, quality of meibomian secretions and increase the TBUT.8,9 Omega-3 fatty acids may be acquired from intake of oily fish, flaxseed oil or supplements available in health food shops. 8,9 In addition to the above measures, patients may be advised to modify their behaviour and environment. For example, the use of a humidifier, avoid excessive contact lens wear and ensure adequate blinking. 51 Secondary care treatment This usually begins with reinforcement of primary care treatment measures and ensuring good compliance. Additional treatment modalities include antibiotics, anti-inflammatories and probing of meibomian glands. Severe lid margin disease and/or associated rosacea may require systemic antibiotics in the form of tetracyclines. These are prescribed for two to three months and may require repeat administration during severe flare-ups. They inhibit the production of bacterial lipases, which serve to alter the consistency of the meibomian oils. In addition to their antibacterial action, tetracyclines are recognised to be potent anti-inflammatory agents, inhibiting the expression of matrix metalloproteinases and other cytokines. 10 This can be supplemented with the short-term use of topical antibiotics (for example chloramphenicol, fusidic acid, and azithromycin) or steroid-antibiotic preparations. Steroids are helpful in reducing inflammation, but prolonged use may lead to a rise in intraocular pressure and development of cataracts. Topical Cyclosporin A may be used as an alternative to steroids and has been Figure 6 Small area of marginal keratitis at the 6 o clock position. There is associated lid margin inflammation and generalised injection of the bulbar conjunctiva shown to be effective in the treatment of blepharitis. It may also alleviate symptoms of concomitant dry eyes. 11 Intraductal meibomian gland probing involves inserting a fine sterile probe into each of the meibomian glands. This has been shown to relieve blockages and improve symptoms. 12 Referral to the Hospital Eye Service (HES) Blepharitis can be managed quite effectively in the primary care setting and does not usually necessitate referral to the HES. Patients who have recurrent flare-ups may conceive that they have received inadequate or inappropriate treatment and may seek onward referral. While referral may be necessary in some cases, it highlights the importance of patient education prior to recommending treatment. Patients with severe disease, persistent symptoms despite good compliance, and ocular surface inflammation (phlyctens, marginal keratitis) should be referred to the HES for consideration of secondary care treatment on a routine basis, although corneal involvement would warrant urgent referral. Tumours of the eyelid margin may mimic blepharitis. Sebaceous cell carcinoma is an aggressive tumour of the meibomian glands which may masquerade as severe blepharitis causing lid margin inflammation, irregularity and ulceration. The recurrence of chalazia at the same site of previous surgery must also raise the suspicion of a tumour. It has a predilection for the upper eyelid and results in high mortality. Basal cell carcinoma of the morphea form may also mimic blepharitis and uncertainty or suspicion of the presence of these tumours must trigger a referral to HES on an urgent basis. MORE INFORMATION References Visit click on the article title and then on references to download. Exam Questions Under the new Enhanced CET rules of the GOC, MCQs for this exam appear online at Please complete online by midnight on March 8, You will be unable to submit exams after this date. Answers will be published on co.uk/cet/exam-archive and CET points will be uploaded to the GOC on March 18, You will then need to log into your CET portfolio by clicking on MyGOC on the GOC website ( to confirm your points. Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills how will you change the way you practice? How will you use this information to improve your work for patient benefit?

Dry Eye Syndrome (DES)

Dry Eye Syndrome (DES) (1) What is Dry eye syndrome (DES)? (2) What causes dry eye syndrome? (3) What are the features of dry eye syndrome? (ii) Irritation and dry eyes This occurs because without adequate