By Dr. Paul Karpecki
Blepharitis is one of the most common conditions eye care practitioners (ECPs) diagnose and yet it is one of the most under-diagnosed conditions! The reason is that blepharitis isn’t usually diagnosed until it is severe, which involves loss of meibomian glands, thinned lashes, advanced erythema, lid edema, and dry eye disease. The fact is that blepharitis, inflammation of the eyelids, begins years or decades prior and only subtle signs exist. Recent research has shown significant bacteria to be present within the follicles of lashes (where you can’t observe) or surrounding the base or in the meibomian glands or lash follicle orifices. Clinicians must look for blepharitis sooner, such as for debris at the base of the lashes; as the lashes grow out, they may include discharge to collarettes. I suggest that ECPs have their patient look down at the slit lamp and scan the upper lash margin for collarettes. Early diagnosis is key to preventing future chronic issues and permanent tissue loss.
While commercial lid scrubs and hydrating compresses are helpful and recommended, additional treatments are necessary. Think of the dental model: the dentist (or more likely the dental hygienist) performs in-office cleaning and various procedural options, but you still brush and floss your teeth at home. Likewise you should see your ECP for in-office procedures and use lid scrubs and hydrating compresses at home.
In office treatments include micro-blepharoexfoliation (MBE) and photobiomodulation such as intense pulsed light (IPL) and low level light therapies (LLLT). We typically combine these treatments. The photobiomodulation kills the microorganism and the mechanical treatment removes debris, residual bio-film, and in the case of demodex, mites and eggs. Advantages of LLLT/IPL include killing the organ-isms as opposed to simply removing them (like MBE). Some disadvantages of tea tree include potential toxicity and damage to meibomian glands, as well as patient discomfort in higher concentrations. Lower concentrations work on milder presentations but may not affect a severe blepharitis presentation. Anti-biotic drops or ointments as well as surfactant-based cleaners will work for bacterial blepharitis but not demodex.
LLLT is a particularly helpful technology for blepharitis. In my experience, we’ve seen dramatic improvement in all forms of blepharitis including bacterial and demodex – especially when combined with IPL. In infectious cases we use the blue LLLT mask, which has particularly good anti-microbial effects, followed by the red LLLT.
Blepharitis is common and needs to be diagnosed early and treated aggressively the moment the first signs of disease are present. Combining at home treatment with in-office procedures appears to best address infection and dermatological forms of blepharitis
1. Nattis A, Perry HD, Rosenberg ED et al. Influence of bacterial burden on meibomian gland dysfunc-tion and ocular surface disease. Clin Ophthalmol. 2019 Jul 12;13:1225-1234.