Dry eyes and blepharitis
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Dry Eyes and Blepharitis. Mitch Menage Consultant Eye Surgeon Leeds Teaching Hospitals Trust. GP Meeting Sep 2006. Dry Eyes and Blepharitis. Common chronic conditions in often unhappy patients ‘Heartsink’. Blepharitis. Chronic inflammation of the lid margins Common Remitting

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Dry eyes and blepharitis

Dry Eyes and Blepharitis

Mitch Menage

Consultant Eye Surgeon

Leeds Teaching Hospitals Trust

GP Meeting Sep 2006


Dry eyes and blepharitis1
Dry Eyes and Blepharitis

Common chronic conditions in often unhappy patients

‘Heartsink’


Blepharitis
Blepharitis

  • Chronic inflammation of the lid margins

  • Common

  • Remitting

  • Range of ages

  • Bilateral

  • Often misdiagnosed as conjunctivitis


Blepharitis1
Blepharitis

  • Lid anatomy

  • Types

  • Associated conditions

  • Symptoms

  • Signs

  • Treatment


Lid anatomy
Lid anatomy

Meibomian/tarsal glands

Glands of Zeiss and Moll



Blepharitis types
Blepharitis-Types

  • Anterior –staphylococcal/dandruff

    • Yellow flakes on lid margin

  • Posterior sebborhoeic

    • Inflamed red oily lid edges



Staphylococcal blepharitis
Staphylococcal Blepharitis

  • More common young patients

  • Chronic infection of base of lashes

  • Staph. Aureus

  • Associated with styes

  • Secondary

    • Papillary conjunctivitis

    • Punctate corneal erosions

    • Marginal keratitis


Seborrhoeic blepharitis
Seborrhoeic Blepharitis

  • More common older patients

  • Excessive lipid secretion meibomian glands

    • Meibomitis/MGD

  • Lid commensals break down to free fatty acids

  • Shiny waxy lids with greasy lashes

  • Secondary

    • Papillary conjunctivitis

    • Punctate corneal erosions


Acne rosacea
Acne Rosacea

  • Strongly associated with seborrhoeic blepharitis

  • Mild forms not diagnosed


Blepharitis symptoms
Blepharitis-Symptoms

  • Sore burning itching irritation of lids

  • Grittiness and watering

  • Mild stickiness particularly on waking

  • Red lid margins

  • Dry eyes


Signs
Signs

  • Red lid margins

  • Greasy material along margin of lids

  • Clogging of meibomian gland openings

  • Mild conjunctival injection

  • Punctate corneal staining

  • Acne Rosacea

  • Styes/chalazions



Treatment
Treatment

  • Patient education!

  • Lid hygiene

  • Hot compresses

    • Warm flannel 10 mins

    • Eyebag

  • Lubricants

  • Antibiotic gel/ointments

  • Oral antibiotic

    • Intermittent steroid ointment


Dry eyes
Dry Eyes

  • Lacrimal apparatus

  • Tear Film

  • Causes/Associated Conditions

  • Symptoms

  • Signs

  • Treatment



Causes of dry eye keratoconjuctivitis sicca
Causes of Dry Eye‘Keratoconjuctivitis Sicca’

  • Lacrimal gland aging

  • Strongly associated with blepharitis

  • Inflammatory conditions

    • Rheumatoid arthritis

    • Sarcoidosis

    • Sjogrens Syndrome


Sjogrens syndrome
Sjogrens Syndrome

  • Very severe dry eyes

  • Middle-aged women

  • KCS/Xerostomia and vasculitic disease

    • Rheumatoid Arthritis

    • SLE

    • Scleroderma

    • Polyarteritis

  • Blood tests

    • ANA 70%

    • SSA(RO) 70% SSB (LA) 40%

    • RhF 60%


Symptoms
Symptoms

  • Feel dry (Can be watery!)

    • No relation to emotional tearing

  • Gritty burning eyes

  • Worsening through day peak in evening

  • Worsened by reading, TV, computer

  • Worsened by air conditioning, central heating, dry arid conditions


Signs1
Signs

  • Often none!

  • Poor tear film on SL with rapid break-up time

  • Punctate staining of cornea inferiorly

  • Filament strands of mucus on cornea

  • Schirmers test


Signs2
Signs

Rapid tear break-up time


Signs3
Signs

Rose Bengal staining


Signs4
Signs

Mucus Filaments



Treatment lifestyle
Treatment - Lifestyle

  • Avoid dry situations

    • Car

    • Air conditioners

    • Irritants cigarette smoke etc.

  • Drugs BP, antidepressant, antihistamine etc

  • Increase humidity

    • Plants, wet towels, radiator trays etc.

  • Humidity chambers

    • Wraparound glasses

    • Swim goggles


Treatment lubricants
Treatment-Lubricants

  • Liquid drops

    • Frequent application

  • Gels

    • More blurring

  • Ointments

    • Usually only at night

    • Nocturnal lagophthalmos

  • Preservative free?






Treatment1
Treatment

  • Anti-inflammatory

    • Steroid

    • Cyclosporin –Restasis

  • Antimucolytic

    • acetylcysteine –Ilube

  • Oral pilocarpine-Salagen

    • Usually only in Sjogrens

    • Side effects/limited efficacy


Treatment2
Treatment

  • Punctal occlusion

    • Cautery

    • Plastic Plugs

    • Smartplugs


Punctal cautery
Punctal Cautery

  • Simple procedure under L/A

  • Often preceded by temporary trial occlusion

  • Cautery inserted into punctum/canaliculus

  • Sometimes not successful

  • Permanent and difficult to reverse

  • More common to use temporary plugs first




Dry eyes and blepharitis2
Dry Eyes and Blepharitis

  • Very common in older patients

  • Chronic remitting problem

  • Not usually serious but constant nuisance

  • Patient Education

    • Lifestyle

    • Regular hygiene/instillation of drops/gels

    • Realistic expectations of treatment!


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