Treating blepharitis to stabilize the tear film and improve visual function after cataract surgery

David A. Goldman, M.D.

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Oftentimes physicians may become disgruntled because a "20/20 patient" is not happy post-operatively because of persistent foreign body sensation or irritation. As patients' expectations continue to increase, we must become more aggressive in treating anything that may lead to patient dissatisfaction. Blepharitis can contribute to tear film dysfunction, and tear film abnormalities have been demonstrated to degrade image quality¹. Certainly diagnosing and beginning treatment prior to surgery is preferable, but the impact of blepharitis can be overlooked by even the most astute ophthalmologists. If not managed pre-operatively, blepharitis may still be treated to improve the tear film, thereby improving comfort and visual function.

Firstly, it is important to evaluate the patient for other conditions that may affect the tear film, namely dry eye and allergy. This can be ruled out by careful examination of the conjunctiva for inflammatory reaction and a Schirmer’s test. Blepharitis can present in conjunction with these problems and, if that is the case, all conditions should be treated.

The American Academy of Ophthalmology 2008 Preferred Practice Pattern (http://one.aao.org/CE/PracticeGuidelines/PPP.aspx) divides blepharitis into the anatomic locations; anterior including the lashes and posterior including the meibomian glands. Frequently a patient will have elements of both anterior and posterior blepharitis, but treatment should be directed at what appears to be the most prominent.

With anterior blepharitis, patients may have significant lid debris or collarettes on the lashes. Madarosis or even matting of the lashes may also be evident. Treatment is often directed at removal of this matter, traditionally in the form of lid scrubs with dilute baby shampoo. Several companies have introduced additional products for this (examples include OCCuSOFT lid scrubs and Theratears SteriLid). Another less thought about but equally important cause of anterior blepharitis is overgrowth of demodex. Baby shampoo and similar products should be avoided in blepharitis patients who do not have anterior disease, as the detergents may further destabilize the tear film. While felt by many to be a normal commensurate organism of the hair follicles, it's been found that treatment of the lids with tea tree oil results in a decreased load of demodex and improvement in blepharitis both symptoms and signs².

Posterior blepharitis can be detected as inspissation of the meibomian glands. Other findings can include lid telangiectasias, frothy tear film, or "toothpaste sign" (expression of thickened meibomian gland secretions via pressure on the lid margin). Traditional therapy has included warm compresses and lid massages to loosen meibomian gland secretions. Additional treatments include antibiotic and anti-inflammatory therapy. Antiobiotics not only decrease bacterial overgrowth on the ocular surface, but have been found to improve meibomian gland function as well. Oral minocycline has been found to alter the meibomian fatty acids³, and tetracycline has been shown to inhibit lipase production⁴. In fact, tetracylcline is extremely effective in the treatment of blepharitis associated with ocular rosacea⁵. Recently topical azithromycin (Azasite, Inspite) has also been described at decreasing the inflammatory signs seen in blepharitis⁶.

Anti-inflammatory therapy is also very effective in the treatment of blepharitis. This can take the form of traditional steroid drops, non-traditional steroid drops such as loteprednol (Lotemax, Bausch & Lomb), or cyclosporine (Restasis, Allergan)⁷.

Nutritional therapy, such as flaxseed oil⁸ and omega-3 fatty acid supplementation, may also improve the quality of meibomian gland secretions.

As important as choosing the proper therapy, one should make sure not to perform improper therapy such as punctal plugs. In a patient with significant blepharitis, plugs will keep the inflammatory mediators of the tear film on the ocular surface. Plugs can be considered, however, once the inflammatory component is under control.

In my practice I have found that the majority of post-cataract blepharitis patients have a majority posterior component, and I will begin therapy with a combination antibiotic/steroid medication such as tobramycin/dexamethasone (Tobradex ST, Tobradex, Alcon) or tobramycin/loteprednol (Zylet, Bausch and Lomb), which have been found very effective in managing blepharitis⁹. However, long term steroid use may lead to increased intraocular pressure and so once the inflammatory component in controlled I will transition to another medication.

Ultimately, these patients can be some of the most challenging patients to come in to your office. However, by appropriately stabilizing the tear film and improving vision, these can also be some of your most appreciative patients.

REFERENCES:

1. Montés-Micó R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg. 2007 Sep;33(9):1631-5.
2. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Cornea. 2007 Feb;26(2):136-43.
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8. Jones SM, Weinstein JM, Cumberland P, Klein N, Nischal KK. Visual outcome and corneal changes in children with chronic blepharokeratoconjunctivitis. Ophthalmology. 2007 Dec;114(12):2271-80.
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