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Today, a husband and wife were in my office for their annual eye exams. The wife had been told by her dermatologist that she had “ocular rosacea”. She asked me if this was possible. She knew that rosacea was a skin condition, and she was surprised she could have it in her eyes. I explained to her that we consider the ocular component of rosacea to be blepharitis. There is a strong association between rosacea of the skin and blepharitis of the eyelids. The term “ocular rosacea” has been around for many years. Technically, it is not correct terminology. But, most ophthalmologists, and dermatologists, understand that it is synonymous with blepharitis. In fact, the physiology of both conditions is similar. Namely, overactivity of the oil glands of the skin and eyelids and sluggish secretions of these oil glands. On the skin, this produces acne, prominent pores in the nose, forehead and cheeks, and dilated blood vessels. On the eyelids, we find accumulation of oil, dandruff, and bacteria. When this material spills into the eye, it causes redness, burning and stinging. This lady’s husband also had rosace and blepharitis. I wondered about their kids. Rosacea is hereditary. Most people with this condition have a Scottish, Irish, or English ancestry. With two parents as fair, and rosacea-prone as this couple, I imagine their kids would have rosacea and blepharitis. I advised this couple, as I do other rosacea/blepharitis patients, to wear a hat and sunscreen to reduce sun damage, and to clean their eyelids once a day with baby shampoo. Since fair skin is more susceptible to skin cancers, a hat with a 360 degree brim offers the best protection.
A recent article mentioned that “ocular surface disease” was common in people taking glaucoma eye drops. Ocular surface disease is a catch-all term for disruption of the cornea and conjunctiva, the outer “surface” of the eye.
It is well known that dryness, allergy, eye drops, and blepharitis, can all cause ocular surface disease. The fact that glaucoma eye drops are associated with ocular surface disease should come as no surprise. Glaucoma eye drops are potent medications which lower intraocular pressure. Potent medications often have potent side effects, including irritancy, or toxicity. In general, the toxicity is minimal. Eye drops are formulated with buffers, and stabilizers, so they are mostly well tolerated. But they must contain the required drug in adequate concentrations, and they must contain preservatives so they do not become contaminated. Since many different kinds of drops are used to treat glaucoma, a less toxic drop can sometimes be substituted for a toxic one. This is frequently done when a patient develops intolerance to a particular glaucoma drop. If a satisfactory substitute cannot be found, glaucoma surgery can often be done, and the need for glaucoma drops can often be eliminated. It is worth repeating that glaucoma eye drops can also have toxicity for the eyelids. So, patients with glaucoma can develop blepharitis from their eye drops. Occasionally, the eyelid inflammation is caused by allergy, or contact dermatitis. More often, it is caused by direct irritancy of the drug, acting on the delicate skin of the eyelid.
We are starting to see interest from the pharmaceutical companies in the treatment of blepharitis. This is not surprising, considering the prevalence, and chronicity of blepharitis, and the size of the market. Recently, I have noticed some discussion at meetings, and even some clinical trials, using the antibiotic eye drops, such as azithromycin, or tobramycin, to treat blepharitis. This is clearly an “off label” use of these eyedrops. In other words, it is a treatment which has not been approved by the FDA. This usually means the company that makes the drug did not perform the rigorous clinical trials to demonstrate that the drug works for this condition. Azithromycin and tobramycin ophthalmic solution, like other antibiotic eye drops, are approved for the treatment of bacterial conjunctivitis. So, the effectiveness of these eye drops for blepharitis is largely anecdotal. There have been some studies, or clinical trials, of azithromycin and tobramycin/dexamethasone eye drops for blepharitis. The ones I have seen were not done in a rigorous manner. Some were “open label”. In other words, the patient and doctor knew what drug was being used. Most had no placebo control. In other words, there was no comparison with an inactive eye drop, which may have worked just as well. To know whether these eye drops really works for blepharitis, we will have to await controlled studies in which the doctors and the patients do not know if they are receiving the active drug or the placebo.
From a common sense point of view, an eye drop would not be expected to provide the best treatment for blepharitis. When an eye drop is instilled, most of it immediately washes out of the eye, and a very small amount comes into contact with the eyelid margin for a very brief time. It is hard to imagine that much of the drug penetrates into the meibomian glands, the oil glands of the eyelid. A more logical treatment would be to remove debris, such as oil and dandruff, from the eye lid using lid scrubs. Then, to rub a drop or ointment directly into the lid margin. The latter is the way I currently treat blepharitis in my practice. It would be nice if an eye drop worked just as well. It might be more convenient to use an eye drop than to use lid scrubs and direct application of medication to the lid margins. However, we will need much stronger evidence that eye drops works before doctors can honestly recommend an eye drop over the standard treatment of blepharitis.
Dietary supplements are popular for the treatment of a wide variety of medical conditions. For blepharitis, omega-3 fatty acids have been suggested as a possible treatment. The rational is that omega-3s have an anti-inflammatory effect. They compete with omega-6 fatty acids for the same enzyme, which converts them to inflammatory mediators, known as prostaglandins.
The ideal ratio of omega-6 to omega-3 in the diet is said to be 4:1, as seen in the Mediterranean diet, rich in cold water fish and natural oils. The typical American diet, containing more red meat and unprocessed oils, has a ratio closer to 18:1. By consuming more omega-3s, in the form of flaxseed oil or fish oil, lower amounts of inflammatory mediators are produced.
Omega-3s have been recommended for the prevention, or treatment, of cancer, heart disease, arthritis, autoimmune disease, and psychiatric disease. Advocates of omega-3s for blepharitis claim a beneficial alteration of the oily, meibomian gland secretions of the eyelids.
Clinical trials, however, show only a mild benefit over placebo. The recommended dose is fairly large, 2 to 5 grams a day. Side effects of omega-3s have been reported, including bleeding, stroke, poor control of diabetes, and even heart problems.
Considering the modest claims for improvement of blepharitis, the inconvenience, and expense, of taking large amounts of a poorly understood dietary supplement, and possible serious medical side effects, I do not prescribe omega-3s for my blepharitis patients. I am sure we will hear anecdotal stories about the benefits of omega-3s, as well as for other dietary supplements, but until we see documentation of more benefits for blepharitis patients, I remain cautious, and unconvinced.
Most people know about styes, and many have personal experience with them. But, what you may not know is that styes are directly linked to blepharitis. In fact, they are one of the ultimate consequences of blepharitis. A stye results from a plugged up oil gland of the eyelid.
You can think of a stye simply as a “pimple” in the eyelid. Along the rim, or margin, of each eyelid, there is a row of twenty or thirty oil glands. These glands extend into the tissue of the eyelid, but their opening is right at the lid margin. The oil they produce contributes to the tears which continually coat the surface of the eye. The oil, in fact, forms the upper layer of the tear film, and helps prevent the tears from evaporating too quickly. In people with blepharitis, the oil glands, known as meibomian glands, can be sluggish, and their openings to the lid margin may become plugged. When that happens, the gland does not stop secreting. Instead, it backs up. Its secretions seep out into the lid tissues, and produce a tender, inflamed nodule in the lid. Sometimes, a stye can be treated successfully with hot compresses and massage. Other times, it has to be drained surgically. This is done by anesthetizing the eyelid, making an incision inside the eyelid, and scooping out the cheesy material forming the abscess. Antibiotic ointment is instilled, and a patch is placed over the closed eyelids for several hours.
Although styes are easily treated in the ophthalmologist’s office, it is not clear we can prevent them from forming. Some believe that if we use daily lid hygiene, and give the lid margins a “once over” with a washcloth and a few drops of baby shampoo, we may be able to discourage styes from forming.