Eyeworld

FALL 2026 | EYEWORLD | 63 C REWIND. REFRESH. REFINE. by Liz Hillman Editorial Co-Director About the physicians Kendall Donaldson, MD, MS Medical Director Bascom Palmer Eye Institute, Plantation Plantation, Florida Stephen Pflugfelder, MD Professor and James and Margaret Elkins Chair in Ophthalmology Baylor College of Medicine Houston, Texas Gerami Seitzman, MD Clinical Professor of Ophthalmology Medical Director Francis I. Proctor Foundation H. Bruce Ostler Chair in International Ophthalmology and Prevention of Blindness University of California, San Francisco San Francisco, California seborrheic), posterior blepharitis (meibomian gland dysfunction [MGD]), and parasitic (De- modex-associated collarettes as pathognomonic). "In practice, precise subtyping is less im- portant than identifying the dominant mecha- nism, and all of the following should be con- sidered: bacterial load/inflammation, biofilm, meibomian gland obstruction, and Demodex in- festation. Subtype labeling may help guide ther- apy, but treatment should be mechanism-driven, not label-driven," Dr. Donaldson said. Dr. Seitzman said most of her blepharitis patients are refractory referral cases, which frames her treatment approach. "When I think of blepharitis, I think more like a dermatologist. I am frequently asking myself questions like: Is this rosacea? Is this atopy? Is this contact dermatitis? Is this seborrhea?" she said. "I think subtyping anterior and posterior blepharitis is important. In our field it's almost Pavlovian to think 'blepharitis' and have the reflex treatment be lid scrubs and warm compresses. But in my opinion, this is not always a great approach." Treating by type As Dr. Seitzman said, she doesn't always recom- mend scrubs and warm compresses for blephari- tis. She thinks that treating by subtype can yield more effective results. "If there is eyelash debris (anterior bleph- aritis), then an eyelid scrub makes sense. But if there is only meibomian gland clogging, lid scrubs don't make sense to me. Conversely, if the lid margin is inflamed, and there is no eyelash debris, lid scrubs can further irritate the lids," Dr. Seitzman said. "Commonly, the rebut- tal to this opinion is that we want to uncap the glands, so we ask patients to scrub their lashes. This doesn't make anatomic sense to me be- cause we do not ask patients to run their fingers across their lid margins (where the meibomian glands are), and it's unclear to me how a tradi- tional eyelid scrub would help unroof a meibo- mian gland. Heat and anti-inflammatories make sense to me for clogged and inflamed glands." An eyelash scrub is beneficial when there is a lot of anterior blepharitis, Dr. Seitzman said. She noted that in her referral prac- tice, most of her patients have already failed B lepharitis diagnosis and treatment have shifted in recent years. From the ability to diagnose blepharitis subtypes to the ability to treat those subtypes specifically, there are the established, over-the-counter options like lid hygiene and warm compresses, procedural treatments, and FDA-approved prescription options. Overall, blepharitis is becoming a more treatable ocular surface disease, and Kendall Donaldson, MD, MS, Stephen Pflugfelder, MD, and Gerami Seitzman, MD, have something to say about it. Blepharitis diagnosis and classification While Dr. Donaldson finds it clinically useful to think of blepharitis as subtypes, she thinks blepharitis is best understood as a multifacto- rial spectrum disease with overlapping drivers. It doesn't necessarily fit into rigid categories, but when it is categorized, these are the main ones: anterior blepharitis (staphylococcal or Saying bye to blepharitis caused by staph, MGD, and Demodex continued on page 64 Posterior blepharitis (MGD, thick secretions, and lid margin telangiectasia) with clean lashes (no anterior blepharitis) Source: Gerami Seitzman, MD Posterior blepharitis (MGD, lid margin telangiectasia) with anterior blepharitis (debris at base of lash margin) Source: Gerami Seitzman, MD

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