Ophthalmology Management

Newsletter

July 2020

The Role of the Eyelid on Ocular Surface Disease

Elizabeth Yeu, MD

Good ocular surface health depends on healthy eyelid blink and function, and this dysfunction can trigger chronic inflammation. A weakened eyelid blink can worsen meibomian gland dysfunction. Table 1 shows a number of eyelid conditions that can lead to ocular surface disease (OSD); it’s important to diagnose and treat them early to prevent progression. The initial examination for OSD should include the Look Lift Pull Push (LLPP) protocol¹ — Look at the lashes, lid, interpalpebral conjunctiva and cornea; Lift the upper lid to check for superior limbic keratoconjunctivitis and superior anterior basement membrane dystrophy; Pull the upper lid to look for floppiness; and Push the lower lid to express the meibomian glands.

Table 1. Eyelid conditions

Blepharitis and MGD
Blepharitis is an under-diagnosed cause of dysfunctional tear syndrome. Anterior blepharitis is most commonly due to staphylococcal infection (i.e. S. aureus, S. epidermides). Demodex mites can affect both the anterior and posterior lid margins, and D. brevis can reside within the meibomian glands. These mites take 2 weeks to mature from the egg to the larval stage, and have an overall life span of up to 3 weeks.

Meibomian gland dysfunction occurs when normal meibomian gland secretions convert from unsaturated lipids that melt at body temperature, to saturated fats that inspissate the meibomian glands. Lid microbes secrete lipases that break down lipids to soaps and fatty acids. Incomplete blink is common, and leads to congestion of meibomian glands, and atrophy.

Diagnosis and Treatment
It’s important to look closely at the lids, and gently compress them to assess the quality and amount of meibum expressed. If blepharitis or MGD is observed, a number of treatments can be considered, as shown in table 2.

Table 2. Treatment options

Erythromycin and azithromycin are macrolides. The anti-inflammatory effects of macrolides have been known for over 40 years, and they prevent the formation of proinflammatory mediators, cytokines, prostaglandins, and tumor necrosis factor α.

Azithromycin can be used off-label for blepharitis. It provides broad coverage and is effective against lid flora commonly associated with blepharitis. It reaches high tissue concentrations, above the minimum inhibitory concentrations, and can be delivered in a sustained release manner for prolonged drug delivery to achieve its anti-inflammatory effects. Dosing is bid for 2 days, qhs for 1 month, and then 1 month on, 1 month off vs. OU qhs for the first week of every month.

Demodex blepharitis can be diagnosed when collarettes are seen on routine slit-lamp exam. This condition occurs when an overgrowth of Demodex folliculorum mites scratch and feed on the skin. The partially digested epithelial cells, keratin, mite waste and eggs combine to form collarettes, which are typically found at the base of the lash but can migrate up as the hair shaft grows.^2-4

Demodex blepharitis has no prescription treatments available at this time, but this will likely change with future innovations that are targeting this disease. Therapies involving tea tree oil (TTO) >20% to 50%, with the active ingredient being terpinen-4-ol, may be useful. For mild cases a TTO shampoo or face wash can be used.

Microblepharoexfoliation can be used to debulk the disease, which is then followed up with maintenance therapy. Hypochlorous acid has been shown to be an effective therapy to reduce the number of Demodex mites. Left unmanaged, Demodex blepharitis may lead to blurred vision, lid and lash abnormalities, inflammation of additional ocular tissues, contact lens discontinuation, suboptimal surgical outcomes, and lower patient quality of life.^2,5-7

Compounded formulations of metronidazole ophthalmic ointment, topical doxycycline drops, and topical clindamycin ointment are also being used as innovative treatments for blepharitis. Oral nutritional supplements may also be helpful. Flaxseed oil (short-chain omega-3 fatty acid) thins meibomian gland oils and thickens the oil layer, but does not suppress inflammation, and fish oil (long-chain omega-3 fatty acid) suppresses inflammation but does not thicken the oil layer. Gamma linoleic acid (GLA) is another supplement that can be used. It has been shown to be an effective anti-inflammatory (in HydroEye), but is not found in regular diet, flaxseed oil or fish oil.

Still other possible treatments include androgen therapy; pulsed light therapy; specialized treatments such as LipiFlow, EyeXpress, Miboflow, iLux, and TearCare; and meibomian gland probing.

Essential Blepharospasms
Blepharospasms can lead to ocular surface disease and worsen a patient’s quality of life. They can also worsen filamentary keratitis. Botulinum toxin A is a very effective treatment for the temporary treatment of orbicularis spasms, and its sequelae on the ocular surface.⁸ High order aberrations, Schirmer I tests, Dry Eye-related Quality of Life Score (DEQS), Ocular Surface Disease Index (OSDI) scores, tear breakup time, and lissamine green staining have all improved after use of botulinum toxin.^9,10

It has been shows that botulinum toxin injection into the medial part of the eyelid improves dry eye signs and symptoms and reduces tear cytokine levels.^11,12 It must be used with caution as it can weaken the orbicularis muscle and affect nasolacrimal pump drainage function.

Cosmetic Contributors to OSD
Cosmetics can have a negative effect on ocular health. Waterproof eye makeup, eyelid tattooing, eyelash extensions, liquid eye make-up removers, and over-the-counter eyelash growth serums can all play a role, as can botox for crow’s feet, botox in a jar (argiriline), Retin-A, ingredients included in commonly used products, and improper practices such as sharing makeup and not replacing products on schedule.

Reference(s):

Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684. doi:10.1016/j.jcrs.2019.03.023
Fromstein SR, Harthan JS, Patel J, et al. Demodex blepharitis: clinical perspectives. Clin Optom (Auckl). 2018;10:57-63. Published 2018 Jul 4. doi:10.2147/OPTO.S142708
Nicholls SG, Oakley CL, Tan A, et al. Demodex species in human ocular disease: new clinicopathological aspects. Int Ophthalmol. 2017;37(1):303–312.
Gao Y-Y, Di Pascuale MA, Li W, et al. High Prevalence of Demodex in Eyelashes with Cylindrical Dandruff. Investig Opthalmology Vis Sci. 2005;46(9):3089. doi:10.1167/iovs.05-0275
American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Panel Guidelines: Blepharitis. San Francisco, California: American Academy of Ophthalmology; 2013.
Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009;7(2 Suppl):S1-S14. doi:10.1016/s1542-0124(12)70620-1
American Optometric Association. Glossary of Common Eye and Vision Conditions. https://www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions
Gumus K, Lee S, Yen MT, et al. Botulinum toxin injection for the management of refractory filamentary keratitis. Arch Ophthalmol. 2012;130(4):446-450. doi:10.1001/archophthalmol.2011.2713
Isshiki Y, Ishikawa H, Mimura O. Changes in ocular higher-order aberrations following botulinum toxin treatment in patients with blepharospasm : BTX improves dry eye in patients with BEB. Jpn J Ophthalmol. 2016;60(6):486-491. doi:10.1007/s10384-016-0469-6
Icabeyoglu S, Sekeroglu HT, Mocan MC, et al. Ocular surface alterations in blepharospasm patients treated with botulinum toxin A injection. Eur J Ophthalmol. 2014;24(6):830-834. doi:10.5301/ejo.5000482
Choi MG, Yeo JH, Kang JW, et al. Effects of botulinum toxin type A on the treatment of dry eye disease and tear cytokines. Graefes Arch Clin Exp Ophthalmol. 2019;257(2):331-338. doi:10.1007/s00417-018-4194-3
Serna-Ojeda JC, Nava-Castaneda A. Paralysis of the orbicularis muscle of the eye using botulinum toxin type A in the treatment for dry eye. Acta Ophthalmol. 2017;95(2):e132-e137. doi:10.1111/aos.13140