Blepharitis is a very common condition that ophthalmologists treat on a daily basis. It is not glamorous or exciting and is frequently overlooked. Furthermore, patients and physicians are often frustrated when dealing with blepharitis since there is no cure and exacerbations are common. Sometimes these patients can be challenging to manage, particularly those with blepharitis associated with acne rosacea, which tends to be recalcitrant to standard therapy. Therefore blepharitis has not been a popular topic for discussion. However, there has recently been renewed interest in blepharitis because it is an important factor affecting vision and comfort after cataract surgery. With improvements in IOL technology and surgical outcomes, the health of the ocular surface can be the limiting variable. Consequently, more attention is being directed toward improving the quality of the tear film by aggressively treating blepharitis.
Blepharitis can be classified in many ways, but the simplest and most widely used is to divide it by location: anterior and posterior. The former is associated with Staphylococcus and seborrheic dermatits, and it affects the anterior lid margin with collarettes and crusting of the lashes. Anterior blepharitis is associated with loss of lashes, pannus, phlyctenules, and corneal infiltrates, and is primarily treated with warm compresses and antibiotic ointment. On the other hand, posterior lid margin disease is an inflammation of the Meibomian glands with telangiectasia, thickened secretions, and tear film debris. Meibomitis is associated with dry eye and chalazia. Treatment consists of lid hygiene and anti-inflammatory medications. Antibiotic-steroid combinations, oral tetracyclines, and nutritional supplements are commonly prescribed, but newer topical agents such as Restasis and Azasite have also proven effective. Often patients have a combination of anterior and posterior blepharitis and there is usually some degree of dry eye disease present as well, so considerable overlap in treatment exists.
Eye surgery disturbs the ocular surface and contributes to ocular surface disease. Corneal surgery in particular interferes with the neural pathway for tear production. This is most commonly associated with laser vision correction, but it may also occur with cataract surgery, especially clear corneal procedures and when corneal relaxing incisions are used to correct astigmatism. Another insult to the ocular surface postoperatively is the increased exposure to benzalkonium chloride in the topical eye drops, which typically include an antibiotic, steroid, and nonsteroidal anti-inflammatory drug.
Surgical trauma, dry eye, and preservative toxicity may all exacerbate blepharitis causing an acute flare-up. This sometimes happens in a previously asymptomatic patient. Fortunately such a scenario is rare, but when it does occur it can be frustrating for the physician and the patient. Therefore, it is imperative not only to recognize and treat blepharitis adequately before surgery, but also be ready to promptly treat postop exacerbations. By doing so, our patients will be happier and they will see better too.
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