When Blepharitis Interferes
With Contact Lens Wear

As eye care providers, we’re familiar with blepharitis and know that it’s generally identified by inflammation of the eyelids. However, it’s a far more complicated condition than that, and can be broken down into different types, based on the location of the inflammation. Patients with any form of blepharitis tend to present with similar symptoms, such as contact lens intolerance, eye irritation, chronic red eyes, and foreign body sensation.¹

The location of inflammation and type of blepharitis does matter in how the condition should be treated. Thus, it is important to correctly identify the type of blepharitis to ensure use of the proper treatment. It’s also important to recognize that chronic treatment is often indicated. Below, I explain how to differentiate between the types of blepharitis and review the contact lens complications it causes that are associated with lens type.

TYPES OF BLEPHARITIS

We can separate blepharitis into two main types: anterior and posterior. Anterior blepharitis is recognized as inflammation of the lid margin. Staphylococcal, seborrheic, and Demodex blepharitis affect the lid margin and are categorized as anterior blepharitis subtypes. Posterior blepharitis is defined as inflammation of the meibomian glands (ie, meibomian gland dysfunction [MGD]).

Staphylococcal and Seborrheic Blepharitis

Staphylococcal blepharitis (Figure 1) is characterized by scaling, crusting, and erythema of the eyelid margin, with circular collarette formation on the base of the cilia.¹ Seborrheic blepharitis is characterized by greasy scaling of the anterior eyelid, often seen on the eyebrows and scalp, as well as the eyelids. Failure to treat either form can lead to ulcerative blepharitis, which is clinically characterized by loss of lashes, punctate epithelial erosions, infiltrates, and corneal neovascularization.

Demodex Blepharitis

Demodex blepharitis (Figure 2) typically involves cylindrical dandruff, whereas Staphylococcal blepharitis appears flakier and more circular. To determine what is happening on your patient’s lid margins, simply have them look down. Collarettes are pathopneumonic for Demodex. To make a definitive diagnosis, extract eyelashes from the lid margin and view them with high magnification to determine whether there is a Demodex infestation. Demodex is also commonly associated with ocular rosacea.¹

Blepharitis Associated With MGD

MGD (Figure 3) is characterized by telangiectatic vasculature along the lid margin, saponification of the meibomian glands, thick meibomian gland secretion, atrophy of meibomian glands, and thickening of the lid margin.¹ Coexisting conditions typically include rosacea or seborrheic dermatitis.¹

TREATMENT OPTIONS

Staphylococcal and seborrheic blepharitis have been successfully treated with lid scrubs, 0.01% hypochlorous acid, topical azithromycin, and mechanical debridement.¹

Demodex blepharitis can be treated with 50% tea tree oil,² and some improved effect has also been found with intense pulsed light therapy.^1,3

Meibomian gland blepharitis is typically treated by debriding the glands, using intense pulsed light therapy, warm compresses, oral doxycycline,^4,5 topical azithromycin,^4,6 and oral azithromycin.¹

In addition to these options, each type of blepharitis can be treated with off-label topical corticosteroids, which have been shown to demonstrate some efficacy in the short term.⁵

Even with the correct diagnosis and proper treatment, blepharitis is known to be chronic, requiring long-term management. Long-term treatment should be focused on the etiology of the inflammation.⁵ (Visit bit.ly/blephTx for a review of recent FDA approvals, in-office lid-clearing procedures, and more therapies in the pipeline.)

CONTACT LENS COMPLICATIONS AND MANAGEMENT

Blepharitis can cause disruption in the tear film, making it problematic for patients to be comfortably fit with contact lenses. However, there are ways to minimize such complications and help keep patients in their lenses, depending on the material and treatment modality.

Soft Contact Lenses

In the case of blepharitis and soft contact lens wear, we need to consider the effect this condition has on wear time and overall patient comfort. Blepharitis can lead to increased deposits on contact lenses, and consequently, increased discomfort. Therefore, daily disposable lenses are preferred over monthly replacement lenses for patients who wear soft contact lenses.

MGD is also associated with giant papillary conjunctivitis (GPC). The degree of GPC may correlate with the severity of blepharitis, although treatment of GPC will help improve blepharitis and contact lens tolerance.^1,7 It may be beneficial to alter the contact lens material to improve the papillary response and contact lens discomfort.⁷

Rigid Gas Permeable Lenses

Rigid gas permeable (RGP) lenses are necessary for some patients. However, because of tear film disruption secondary to blepharitis, deposits on the lenses can occur. This can lead to reduced wear time and comfort with RGP lenses.

In addition to being treated for their blepharitis, patients should be educated on maintaining a more rigorous cleaning regimen for their RGP lenses. This may include using a lens cleaner, such as Progent (Menicon America) or Boston Advance Cleaner (Bausch + Lomb), adding a treatment to their lens to decrease deposits, or having in-office lens polishing done. Whichever method or methods are employed, keeping the lenses free of debris will increase comfort and decrease infection rates.

Scleral Lenses

Scleral lenses can be a good option for patients with blepharitis, if care is taken to ensure that they have clean lid margins for best success. It is important to be aware that these lenses tend to accumulate more deposits, which can lead to poorer visual outcomes. Adding a coating to the lens can help increase the wettability and decrease the buildup of deposits. It is worth note that an additional coating may limit the cleaning options available for the lens. Placing the lens on the eye with a conditioning solution on the anterior surface can also help decrease deposits, improving visual and comfort outcomes.

HELP PATIENTS GET THE MOST OUT OF THEIR LENS WEAR

Blepharitis is common, but can be easy to overlook. With vigilant differentiation of blepharitis type, use of appropriate treatment, and proper patient expectations, we can increase positive clinical outcomes and prolong the use of contact lens wear for our patients with this chronic condition.