Blepharitis Treatment Tactics

Ocular surface disease (OSD), including blepharitis, dry eye disease, and allergic conjunctivitis, is more prevalent now than ever.¹ Our lifestyles, both pre- and post-pandemic, which often consist of staring at some type of digital screen for hours every day, have contributed to the growing prevalence of these conditions.

It is vital that, as primary eye care providers, we evaluate and help manage OSD to address symptoms leading to discomfort. Treatment does not start and end with artificial tears.

I have been the sole optometric physician in a general ophthalmology practice for the past decade and, over time, I have come to specialize in OSD, while my ophthalmology colleagues focus more on surgical treatments. In this article, I offer some tips for managing and treating blepharitis based on my own clinical experience.

ACTIONS SPEAK LOUDER THAN WORDS

There are many ways to emphasize to patients that you genuinely care about their ocular health, but the most effective way is to inquire about their comfort. Patients tend to withhold complaints about their ocular symptoms because they are more concerned about their vision.

Screening for crust, meibomian gland function, tear meniscus, tear quality, conjunctival and corneal staining, and signs of inflammation is crucial in detecting OSD. Complications of blepharitis and dry eye, including chalazion and blurred vision, have comprised the majority of my problem-based visits. I can confidently say that treating and managing blepharitis and dry eye have become the bread and butter of the services I offer.

BASIC BLEPHARITIS MANAGEMENT

Basic blepharitis treatment includes eyelid hygiene, heat treatment, and replenishment of tears to improve comfort and vision. Some patients are apprehensive about the treatments that we propose to them because they believe they are asymptomatic (or they are uninterested in taking on the homework that we prescribe). This is where effective communication and education play a key role. Management of blepharitis starts with the education of patients about their condition and the severity of their personal case.

We recently purchased a slit-lamp camera to show patients the condition of their meibomian glands including the quality of oil secretion, or lack thereof, when expressed at the slit lamp. You can also showcase and document the signs of OSD on their cornea and conjunctiva. The slit-lamp camera has improved patient interest and compliance and has also been a revenue generator. Slit-lamp pictures are a billable service and allow you to show patients the initial status of their condition and how it may have improved or worsened on follow-up.

We offer patients an option to purchase products to help them manage their condition at home. In addition, we have an in-office treatment available to patients: a basic heating device that we place on the patient’s eyelids followed by a manual expression of their lids at the slit lamp, to kick-start at-home maintenance. This treatment has proven to be effective for patients who have moderate to severe meibomian gland dysfunction. Therapy may be repeated at patient-specific intervals and as frequently as quarterly. There are numerous devices on the market that provide a similar treatment, but we decided to start with a more economic option.

We also sell individual blepharitis products, such as eyelid wipes, heat masks, nighttime ointment, eyelid spray, and preservative-free artificial tears. We have a blepharitis and dry eye kit available that includes eyelid wipes, a heat mask, and preservative-free artificial tears. The products also include great educational handouts for patients and have become very popular. These offerings have proven to be convenient for patients and lucrative for the practice. Between blepharitis and dry eye product sales, slit lamp photos, and in-office treatment, we’re on schedule to collect an additional $20,000 in net revenue this year. This may not seem like a significant amount of profit, but it translates to greater patient compliance, satisfaction, and referrals. Patients are pleased to have treatment options and access to doctor-promoted products that they can trust.

MEDICAL MANAGEMENT OF BLEPHARITIS

Management of blepharitis with medication includes the use of topical and oral antibiotics, topical steroids, and topical steroid and antibiotic combinations. It is imperative to rule out treatment options based on drug allergies and side effects. Medical management should always be paired with at-home maintenance of eyelid hygiene and heat treatment (see Proper Eyelid Hygiene).

While counseling patients, I always make them aware that blepharitis and dry eye are chronic conditions and will require lifelong maintenance. Treatment regimens should depend on the severity of the disease and patient capability in order to avoid treatment overload and lack of compliance. Systemic conditions, such as rosacea and autoimmune diseases, may play a significant role in the severity of a patient’s blepharitis and dry eye. Comanaging patients with dermatologists and rheumatologists may be necessary in severe cases of OSD.

Although mild blepharitis can be treated with nonmedical modalities, moderate to severe blepharitis should almost always be treated with one or more medical treatments. If a patient is experiencing an acute flare-up, a topical antibiotic–steroid combination would be an appropriate adjunctive treatment to eyelid hygiene and heat compresses. Use of topical antibiotic–steroid drops or ointments should end around 3 weeks to avoid side effects such as elevated IOP. The oral antibiotic of choice for blepharitis treatment is doxycycline and is used for chronic symptoms and acute flare-ups that do not respond adequately to topical treatments. Oral doxycycline can be prescribed for short or long-term, low-dose treatments with taper. Preservative-free artificial tears and cyclosporine ophthalmic emulsion 0.05%/0.09% (Restasis, Allergan/Cequa, Sun Ophthalmics) or lifitegrast ophthalmic solution 5% (Xiidra, Novartis) may be used for long-term control of ocular symptoms.

A WORTHWHILE INVESTMENT

Blepharitis and dry eye detection and management can be mutually beneficial for providers and their patients. These conditions are present in the majority of patients and proper time and attention must be given in order to provide comprehensive care. Dedicating additional chair time to patients with OSD will help grow your practice and ensure satisfaction.

For optometrists who are working in an ophthalmology setting or providing surgical comanagement, treatment of dry eye and blepharitis can optimize refractive outcomes. Optimizing the ocular surface and decreasing infectious and inflammatory load is important both pre- and postoperatively—especially for patients undergoing invasive procedures.