In part two of his two part series, Dr. Schachter discusses the signs and symptoms of blepharitis, treatments, and practice management. View part one, Blepharitis - Overview and Prevalence.
Blepharitis, like many ocular surface diseases, is a condition where signs and symptoms don't always match. Therefore, it is often overlooked. The reason for this may be that blepharitis is a chronic, progressive condition. In our practice, we screen for the disease and treat it early. If you let it progress it will be harder to treat.
Common signs associated with blepharitis include cylindrical dandruff, which is pathognomonic for Demodex blepharitis. Another common sign is conjunctival hyperemia. In addition, look for lid telangiectasia, lid inflammation, madarosis, uneven lash distribution, and a scalloped appearance to the lid margin due to lash distention.
Symptoms may include itchy lids, burning, and a foreign body sensation. In addition, pterygium and chalazion occur at increased frequency when Demodex blepharitis is present. Be sure to look closely when you see these conditions.
As most blepharitis tends to be due to Demodex infestation, the best way to treat it is to attack the culprit. While many lid scrubs do a good job of cleaning up the waste of Demodex (think janitor) tea tree oil attacks the cause of blepharitis (think exterminator). While total eradication of mites is not realistic, it is a reasonable goal to reduce their numbers. Tea tree oil is toxic to Demodex but 4-terpineol is the most potent part of tea tree oil. I recommend the use of Cliradex® moist towelettes for these types of patients. The Cliradex formulation isolates the 4-terpineol molecule as its key ingredient, which allows the use of tea tree oil at a reduced concentration.
With regard to practice management, there are a few considerations, starting with explaining the condition to patients and developing a management protocol. I've learned that it's best to avoid telling patients that they have a lot of bugs living on their eyelids. I take pictures of the lashes and tell them they have a very common dandruff-like condition that should be treated. If pressed for the cause, I tell them that everybody has some mites, they simply have too many, and we need to reduce their numbers.
For mild to moderate cases, I prescribe Cliradex b.i.d. for one month, and then do a follow-up. Assuming everything is under control, we go to every day usage for ongoing maintenance. For severe cases, I like to kick off treatment with Cliradex Complete®, an easy-to-use in-office procedure that uses a stronger concentration of 4-terpineol applied precisely by me. We then do Cliradex wipes at home twice a day and recheck in one month.
As tea tree oil can have a strong sensation around the eyes, it is important to have your staff demonstrate the wipes on the day they are prescribed. We have patients use them on their entire face, however along their lash line, we advise that they dab the towelette or wipe gently; it should not be considered a scrubbing or rubbing procedure. We then recommend that they fan their face and lids after application with their eyes shut. This will help alleviate the tingling sensation. Most patients do just fine with the way it feels as long as they know what to expect.
In our practice, we want our patients to look, feel, and see their best. Treating blepharitis is a rewarding way to achieve this goal.