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!

1