1. Dry Eyes and Blepharitis Mitch Menage Consultant Eye Surgeon Leeds Teaching Hospitals Trust Mitch Menage Consultant Eye Surgeon Leeds Teaching Hospitals Trust GP Meeting Sep 2006

2. Dry Eyes and Blepharitis Common chronic conditions in often unhappy patients ‘Heartsink’ Common chronic conditions in often unhappy patients ‘Heartsink’

3. Blepharitis  Chronic inflammation of the lid margins  Common  Remitting  Range of ages  Bilateral  Often misdiagnosed as conjunctivitis  Chronic inflammation of the lid margins  Common  Remitting  Range of ages  Bilateral  Often misdiagnosed as conjunctivitis

4. BlepharitisBlepharitis  Lid anatomy  Types  Associated conditions  Symptoms  Signs  Treatment  Lid anatomy  Types  Associated conditions  Symptoms  Signs  Treatment

5. Lid anatomy Meibomian/tarsal glands Glands of Zeiss and Moll

6. Lid anatomy

7. Blepharitis-Types  Anterior –staphylococcal/dandruff  Yellow flakes on lid margin  Posterior sebborhoeic  Inflamed red oily lid edges  Anterior –staphylococcal/dandruff  Yellow flakes on lid margin  Posterior sebborhoeic  Inflamed red oily lid edges

8. Blepharitis

9. Staphylococcal Blepharitis  More common young patients  Chronic infection of base of lashes  Staph. Aureus  Associated with styes  Secondary  Papillary conjunctivitis  Punctate corneal erosions  Marginal keratitis  More common young patients  Chronic infection of base of lashes  Staph. Aureus  Associated with styes  Secondary  Papillary conjunctivitis  Punctate corneal erosions  Marginal keratitis

10. Seborrhoeic Blepharitis  More common older patients  Excessive lipid secretion meibomian glands  Meibomitis/MGD  Lid commensals break down to free fatty acids  Shiny waxy lids with greasy lashes  Secondary  Papillary conjunctivitis  Punctate corneal erosions  More common older patients  Excessive lipid secretion meibomian glands  Meibomitis/MGD  Lid commensals break down to free fatty acids  Shiny waxy lids with greasy lashes  Secondary  Papillary conjunctivitis  Punctate corneal erosions

11. Acne Rosacea  Strongly associated with seborrhoeic blepharitis  Mild forms not diagnosed  Strongly associated with seborrhoeic blepharitis  Mild forms not diagnosed

12. Blepharitis-SymptomsBlepharitis-Symptoms  Sore burning itching irritation of lids  Grittiness and watering  Mild stickiness particularly on waking  Red lid margins  Dry eyes  Sore burning itching irritation of lids  Grittiness and watering  Mild stickiness particularly on waking  Red lid margins  Dry eyes

13. SignsSigns  Red lid margins  Greasy material along margin of lids  Clogging of meibomian gland openings  Mild conjunctival injection  Punctate corneal staining  Acne Rosacea  Styes/chalazions  Red lid margins  Greasy material along margin of lids  Clogging of meibomian gland openings  Mild conjunctival injection  Punctate corneal staining  Acne Rosacea  Styes/chalazions

14. Chalazion

15. TreatmentTreatment  Patient education!  Lid hygiene  Hot compresses  Warm flannel 10 mins  Eyebag  Lubricants  Antibiotic gel/ointments  Oral antibiotic  Intermittent steroid ointment  Patient education!  Lid hygiene  Hot compresses  Warm flannel 10 mins  Eyebag  Lubricants  Antibiotic gel/ointments  Oral antibiotic  Intermittent steroid ointment

16. Dry Eyes  Lacrimal apparatus  Tear Film  Causes/Associated Conditions  Symptoms  Signs  Treatment  Lacrimal apparatus  Tear Film  Causes/Associated Conditions  Symptoms  Signs  Treatment

17. Lacrimal anatomy

18. Causes of Dry Eye ‘Keratoconjuctivitis Sicca’  Lacrimal gland aging  Strongly associated with blepharitis  Inflammatory conditions  Rheumatoid arthritis  Sarcoidosis  Sjogrens Syndrome  Lacrimal gland aging  Strongly associated with blepharitis  Inflammatory conditions  Rheumatoid arthritis  Sarcoidosis  Sjogrens Syndrome

19. Sjogrens Syndrome  Very severe dry eyes  Middle-aged women  KCS/Xerostomia and vasculitic disease  Rheumatoid Arthritis  SLE  Scleroderma  Polyarteritis  Blood tests  ANA 70%  SSA(RO) 70% SSB (LA) 40%  RhF 60%  Very severe dry eyes  Middle-aged women  KCS/Xerostomia and vasculitic disease  Rheumatoid Arthritis  SLE  Scleroderma  Polyarteritis  Blood tests  ANA 70%  SSA(RO) 70% SSB (LA) 40%  RhF 60%

20. Symptoms  Feel dry (Can be watery!)  No relation to emotional tearing  Gritty burning eyes  Worsening through day peak in evening  Worsened by reading, TV, computer  Worsened by air conditioning, central heating, dry arid conditions  Feel dry (Can be watery!)  No relation to emotional tearing  Gritty burning eyes  Worsening through day peak in evening  Worsened by reading, TV, computer  Worsened by air conditioning, central heating, dry arid conditions

21. Signs  Often none!  Poor tear film on SL with rapid break-up time  Punctate staining of cornea inferiorly  Filament strands of mucus on cornea  Schirmers test  Often none!  Poor tear film on SL with rapid break-up time  Punctate staining of cornea inferiorly  Filament strands of mucus on cornea  Schirmers test

22. Signs Rapid tear break-up time

23. Signs Rose Bengal staining

24. Signs Mucus Filaments

25. Schirmers Test

26. Treatment - Lifestyle  Avoid dry situations  Car  Air conditioners  Irritants cigarette smoke etc.  Drugs BP, antidepressant, antihistamine etc  Increase humidity  Plants, wet towels, radiator trays etc.  Humidity chambers  Wraparound glasses  Swim goggles  Avoid dry situations  Car  Air conditioners  Irritants cigarette smoke etc.  Drugs BP, antidepressant, antihistamine etc  Increase humidity  Plants, wet towels, radiator trays etc.  Humidity chambers  Wraparound glasses  Swim goggles

27. Treatment-LubricantsTreatment-Lubricants  Liquid drops  Frequent application  Gels  More blurring  Ointments  Usually only at night  Nocturnal lagophthalmos  Preservative free?  Liquid drops  Frequent application  Gels  More blurring  Ointments  Usually only at night  Nocturnal lagophthalmos  Preservative free?

28. Liquid Lubricants

29. Gel Lubricants

30. Ointments

31. New Treatments

32. Treatment  Anti-inflammatory  Steroid  Cyclosporin –Restasis  Antimucolytic  acetylcysteine –Ilube  Oral pilocarpine-Salagen  Usually only in Sjogrens  Side effects/limited efficacy  Anti-inflammatory  Steroid  Cyclosporin –Restasis  Antimucolytic  acetylcysteine –Ilube  Oral pilocarpine-Salagen  Usually only in Sjogrens  Side effects/limited efficacy

33. Treatment  Punctal occlusion  Cautery  Plastic Plugs  Smartplugs  Punctal occlusion  Cautery  Plastic Plugs  Smartplugs

34. Punctal Cautery  Simple procedure under L/A  Often preceded by temporary trial occlusion  Cautery inserted into punctum/canaliculus  Sometimes not successful  Permanent and difficult to reverse  More common to use temporary plugs first  Simple procedure under L/A  Often preceded by temporary trial occlusion  Cautery inserted into punctum/canaliculus  Sometimes not successful  Permanent and difficult to reverse  More common to use temporary plugs first

35. Punctal Plugs

36. Smartplugs

37. Dry Eyes and Blepharitis  Very common in older patients  Chronic remitting problem  Not usually serious but constant nuisance  Patient Education  Lifestyle  Regular hygiene/instillation of drops/gels  Realistic expectations of treatment!  Very common in older patients  Chronic remitting problem  Not usually serious but constant nuisance  Patient Education  Lifestyle  Regular hygiene/instillation of drops/gels  Realistic expectations of treatment!