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Dry Eyes and Dry Eyes and Blepharitis Blepharitis Mitch Menage Consultant Eye Surgeon Leeds Teaching Hospitals Trust GP Meeting Sep 200

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  • Dry Eyes and BlepharitisMitch MenageConsultant Eye SurgeonLeeds Teaching Hospitals TrustGP Meeting Sep 2006

  • Dry Eyes and BlepharitisCommon chronic conditions in often unhappy patientsHeartsink

  • BlepharitisChronic inflammation of the lid marginsCommonRemittingRange of agesBilateralOften misdiagnosed as conjunctivitis

  • BlepharitisLid anatomyTypesAssociated conditions SymptomsSignsTreatment

  • Lid anatomyMeibomian/tarsal glandsGlands of Zeiss and Moll

  • Lid anatomy

  • Blepharitis-TypesAnterior staphylococcal/dandruffYellow flakes on lid marginPosterior sebborhoeicInflamed red oily lid edges

  • Blepharitis

  • Staphylococcal BlepharitisMore common young patientsChronic infection of base of lashesStaph. AureusAssociated with styesSecondaryPapillary conjunctivitisPunctate corneal erosionsMarginal keratitis

  • Seborrhoeic BlepharitisMore common older patientsExcessive lipid secretion meibomian glandsMeibomitis/MGDLid commensals break down to free fatty acidsShiny waxy lids with greasy lashesSecondaryPapillary conjunctivitisPunctate corneal erosions

  • Acne RosaceaStrongly associated with seborrhoeic blepharitisMild forms not diagnosed

  • Blepharitis-SymptomsSore burning itching irritation of lidsGrittiness and wateringMild stickiness particularly on wakingRed lid marginsDry eyes

  • SignsRed lid marginsGreasy material along margin of lidsClogging of meibomian gland openingsMild conjunctival injectionPunctate corneal stainingAcne RosaceaStyes/chalazions

  • Chalazion

  • TreatmentPatient education!Lid hygieneHot compressesWarm flannel 10 mins EyebagLubricantsAntibiotic gel/ointmentsOral antibioticIntermittent steroid ointment

  • Dry EyesLacrimal apparatusTear FilmCauses/Associated ConditionsSymptomsSignsTreatment

  • Lacrimal anatomy

  • Causes of Dry EyeKeratoconjuctivitis SiccaLacrimal gland agingStrongly associated with blepharitisInflammatory conditionsRheumatoid arthritisSarcoidosisSjogrens Syndrome

  • Sjogrens SyndromeVery severe dry eyesMiddle-aged womenKCS/Xerostomia and vasculitic disease Rheumatoid ArthritisSLESclerodermaPolyarteritisBlood testsANA 70%SSA(RO) 70% SSB (LA) 40%RhF 60%

  • SymptomsFeel dry (Can be watery!)No relation to emotional tearingGritty burning eyesWorsening through day peak in eveningWorsened by reading, TV, computerWorsened by air conditioning, central heating, dry arid conditions

  • SignsOften none!Poor tear film on SL with rapid break-up timePunctate staining of cornea inferiorlyFilament strands of mucus on corneaSchirmers test

  • SignsRapid tear break-up time

  • SignsRose Bengal staining

  • SignsMucus Filaments

  • Schirmers Test

  • Treatment - Lifestyle

    Avoid dry situationsCarAir conditioners Irritants cigarette smoke etc.Drugs BP, antidepressant, antihistamine etcIncrease humidity Plants, wet towels, radiator trays etc.Humidity chambersWraparound glassesSwim goggles

  • Treatment-LubricantsLiquid dropsFrequent applicationGelsMore blurringOintmentsUsually only at nightNocturnal lagophthalmosPreservative free?

  • Liquid Lubricants

  • Gel Lubricants

  • Ointments

  • New Treatments

  • TreatmentAnti-inflammatorySteroidCyclosporin RestasisAntimucolytic acetylcysteine IlubeOral pilocarpine-SalagenUsually only in SjogrensSide effects/limited efficacy

  • TreatmentPunctal occlusionCauteryPlastic PlugsSmartplugs

  • Punctal CauterySimple procedure under L/AOften preceded by temporary trial occlusionCautery inserted into punctum/canaliculusSometimes not successfulPermanent and difficult to reverseMore common to use temporary plugs first

  • Punctal Plugs

  • Smartplugs

  • Dry Eyes and BlepharitisVery common in older patientsChronic remitting problemNot usually serious but constant nuisancePatient EducationLifestyleRegular hygiene/instillation of drops/gelsRealistic expectations of treatment!