Lid Infections & Management

1. Lid Infections &Management

2. Blepharitis: • An inflammation of the eyelid. • Classification from McCulley et al (1982). • Anterior Lid • Seborrheic blepharitis • Staphylococcal blepharitis • Mixed blepharitis • Posterior Lid 1) Meibomian Gland Dysfunction (MGD) - seborrheic & rosacea *** Bartlett & Jaanus pp 491 – 495.

3. Seborrheic Blepharitis • Causes maybe Demodex folliculorum but evidence also points to a yeast, Pityrosporum ovale • Tends to have a long course. • Symptoms can include: 1) FB sensation 2) Mattering 3) Burning of the eyes

4. Seborrhea: • A disorder of the sebaceous glands. • Tends to effect the scalp, ears & face. • Can be subtle. Consider a dermatology consult.

5. Seborrheic Blepharitis: • Lid margins may be reddened. • Note greasy scales called scurfs. • Approximately 15% of patients with seborrheic blepharitis develop an associated conjunctivitis or keratitis.

6. Seborrheic Blepharitis:

7. Management of Seborrheic Blepharitis: • Hygiene is the key. • Warm compresses x 5 – 10 minutes 2 – 4 times daily followed by lid scrubs. • Treat the associated dandruff. • Bacterial infections are often associated with the seborrhea.

8. Lid Scrubs: • Commercially available pads. • Baby shampoo. • May need to be diluted for some patients.

9. Other Treatment Options in Seborrheic Blepharitis • A bacterial infection may be associated in non-responsive cases. • Consider lid scrubs with bacitracin or erythromycin ung. • Apply twice daily for 3 weeks.

10. Bacitracin • Inhibits cell wall synthesis. • Staph and Strept are sensitive but most Gram negative bugs are resistent. • Unstable in solution. Available as ung only. • Hypersensitivity to the drug can occur but is rare. • Available by a number of manufacturers.

11. Erythromycin: • Is a Macrolide antibiotic. • Macrolides inhibit bacterial protein synthesis by binding to the 50S ribosome. • Low toxicity because they do not bind to human ribosomes. • Poor activity against H. influenzae. • Available in topical, oral and IV preparations.

12. Oral Macrolide Treatment: • Probably over-kill for Seborrheic Blepharitis: 1) Clarithromycin (Biaxin) *twice the half-life of oral erythromycin. *dosage is 250 to 500 mg BID x 7 to 14 days. 2) Azithromycin (Zithromax, Z-Pak) *its extended half-life allows for once-daily dosing *dosage is 500 mg on day one followed by 250 mg once daily on days 2 through 5.

13. Staphylococcal Blepharitis: • According to Groden et al (1991) the most commonly associated organisms found in chronic blepharitis are: 1.) Staphylococcus epidermidis 2.) Proprionibacterium acnes 3.) Corynebacterium species 4.) Staphylococcus aureus

14. Staph. Blepharitis Causative Agents: Corynebacterium species Staphylococcus species Proprionibacterium species

15. Pathophysiology of Bacterial Blepharitis • Metabolic by-products interact with the bodies defenses. • Sensitivities • Exotoxins • Enzymes (coagulase, hyaluronidase…) • Neurotoxins, Enterotoxin… • Endotoxins?

16. Staphylococcal Blepharitis: • Hard, brittle scales surrounding the lashes. • Collarettes at lash base • Red lid margin. • Chronic cases may show lash loss (madarosis), trichiasis and thickened lid margins (tylosis ciliaris).

17. Staphylococcal Blepharitis: • Note: Hard scales Reddened margins • Symptoms include: 1) FB sensation 2) Mattering in A.M. 3) Itching, Tearing and Burning

18. Staphylococcal Blepharitis:

19. Topical Treatment of Staph. Blepharitis 1) Attention to lid hygiene - Lid scrubs, warm compresses 2) Topical Antibiotic ointment - Erythromycin & Bacitracin ung is the treatment of choice. - Tetracycline & Aminoglycosides can be effective. *Can be scrubbed onto the lids after hot compresses. - Use for 2 – 8 weeks. Consider alternating with different antibiotic to minimize resistance.

20. Oral Treatment of Staph Blepharitis • Bacterial lipases in oil glands may be source of the disease. • Oral antibiotic treatment may surpass hygiene as the treatment of choice. • Tetracycline or Erythromycin: • 250mg QID initially then 250mg QD

21. Tetracyclines: • They work by entering the bacterial cell by active transport and binding to the 30S ribosome subunit and blocks the binding of tRNA. • Very broad spectrum of activity. • Usual dose is 250mg QID or Doxycycline 100mg BID.

22. Side Effects from Oral Tetracyclines: • Various degrees of GI upset. • Taken with food can minimize this. • Can produce a negative nitrogen balance and increased BUN levels. • Children younger than 8 y.o. and pregnant women should avoid. • Teeth discoloration.

23. Tetracycline Teeth Discoloration

24. Pearls about Blepharitis • Most cases are a mix of Staph and seborrheic changes. • Watch for associated conjunctivitis. • Keratitis may be present as well as dry eyes.

25. A Word About Betadine • Anesthetize the eye with 0.5% proparacaine • Instill 2 to 3 drops of 5% Ophthalmic Prep Betadine Solution • Have the patient gently close his/her eyes and roll the eyes around to fully expose all the conjunctival surfaces. • With the patient’s eye closed, use either your gloved finger or a cotton swab moistened with Betadine, and rub along the eyelid margins to eradicate any resident virus there. • After 60 seconds, lavage the ocular tissues with any sterile saline irrigation solution