By Dr. Paul Karpecki
Blepharitis, including meibomian gland dysfunction (MGD), affects over 35 million people and that number underestimates the true population who suffer from this condition. While most patients are treated with artificial tears and eyelid hygiene, I’ve found that in-office procedures can be more effective in moderate to severe cases. With a plethora of options from microblepharoexfoliation to thermal pulsation to photobiomodulation, what’s the best choice to bring the most relief to patients?
The decision of how to treat anterior blepharitis patients depends a lot on what you see clinically. There are three types of blepharitis one can diagnose and different treatment options for each: demuxed blepharitis, staphylococcal blepharitis, and seborrheic forms. While microblepharoexfoliation (MBE) or Blephex might work in all three cases, they are most effective in seborrheic and bacterial forms like staphylococcal blepharitis. Additionally, LLLT treatment with the blue-light mask can positively affect bacterial blepharitis. In my experience, the most effective options for demodex blepharitis are blue-light Low Level Light Therapy (LLLT) and Intense Pulsed Light (IPL). Blue LLLT alone will work but there is an enhanced effect when combining it with IPL. This can even be followed by microblepharoexfoliation (MBE) to de-bulk the collarettes. In my experience, MBE does not kill demodex like blue light LLLT with IPL, but it helps remove the remaining collarettes and debris. If you do not have access to MBE, you can use lid scrubs – preferably one with Manuka extract – after the LLLT procedure.
The more difficult decision may come from the multitude of treatments for posterior blepharitis that range from thermal pulsation to IPL and LLLT. Fortunately, that decision can be made based on the pathology. For example, a patient with easy meibomian gland expression, but paste-like or turbid meibum, can do well with thermal pulsation or red-light LLLT. A patient with ocular rosacea, often identified via telangiectatic vessels on the lid margin, will do better with IPL. Likewise, patients with no visible meibomian gland expression diagnostically seem to do better with IPL followed by red-light LLLT.
I haven’t had a lot of success with using IPL for chalazion in my practice, but I have had positive outcomes with red-light LLLT. Likewise, hordeola responds very well to LLLT treatments with the red-light mask.
With so many options for in-office treatment of blepharitis, it helps to look closely at the specific pathology and then customize the treatment. For the majority of conditions LLLT is most versatile, but combining IPL with LLLT can be extremely effective as can MGE with an LLLT for anterior blepharitis.