Eyeworld

JULY 2023 | EYEWORLD | 61 C BEST PRACTICES About the physicians Vincent de Luise, MD Assistant Clinical Professor of Ophthalmology Yale University School of Medicine New Haven, Connecticut Henry Perry, MD Chief, Cornea Service Nassau University Medical Center East Meadow, New York by Ellen Stodola Editorial Co-Director A ccording to Vincent de Luise, MD, blepharitis is one of the most com- mon conditions seen by ophthalmol- ogists. "In one large study of oph- thalmology offices, almost 40% of patients had a diagnosis of blepharitis on initial examination," he said. 1 This inflammation of the eyelid margins can be acute or chronic and has a multitude of etiologies, including allergic, infectious, immune, systemic, and neoplastic causes. Something that adds to the complexity of diagnosing blepharitis is the fact that it may not be symptomatic at presentation. Additional- ly, blepharitis and dry eye disease often co-exist, which can make diagnosis and stratification confusing and difficult, Dr. de Luise said. For years, people have been talking about blepharitis, dry eye disease, and meibomian gland disease, said Henry Perry, MD. "Most of us have noticed that sometimes it's a combination of all three in patients." He said that James Rynerson, MD, developed a theory that unites dry eye, meibomian gland disease, and blepha- ritis. They are all related and variations on the same theme. "He thought they all come from bacteria forming biofilm," he said. Bacteria col- onization starts to affect everyone between 2–4 years old. These bacteria continue to increase during one's lifetime and form biofilms on the eyelid margins that slowly progress. "If they're on eyelid margins, the first place biofilm would go is the lash follicles, and the lash follicles get inflamed during the teenage or early adult years," Dr. Perry said, adding that this inflamma- tion of the lash follicles is anterior blepharitis. The bacterial biofilm continues to migrate into meibomian glands, which leads to meibo- mian gland dysfunction. Later in life, it reaches into the accessory lacrimal glands and leads to dry eye syndrome (aqueous deficiency). This was discussed in a study by Dr. Perry and Dr. Rynerson in 2016 in Clinical Ophthalmology .2 As far as how common blepharitis is, Dr. Perry said it is basically universal after age 70. The largest studies that have been done were in the military, and they showed that in recruits, usually around age 20, the incidence was 7%. Looking at retirees in their 50s, the incidence went up to 70%. Breakdown of blepharitis and types Dr. Perry said the main types of blepharitis were originally described by James McCulley, MD. "Most of us look at blepharitis in terms of being anterior or posterior, and that refers to the lid margin," he said. The lid margin can be divided into two parts. The anterior contains the lashes, and the posterior contains the meibomian glands. An- terior blepharitis occurs in younger people, Dr. Perry said, and posterior usually occurs in older people, but it becomes relatively common after the age of 30. For example, 30% of people over age 30 have posterior blepharitis, and 50% of people age 50 have posterior blepharitis. "The way to distinguish them is anterior blepharitis has edema and redness of the lash margin and will form anterior abscesses at the lash margin," Dr. Perry said. Posterior blepharitis will have pouting of the meibomian gland orifices and often has inspissation of dried secretions and Blepharitis: types, presentation, and treatment continued on page 62 Cylindrical dandruff Source: Henry Perry, MD

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