Ординатура / Офтальмология / Английские материалы / The Eye Care Sourcebook_Lavine_2001

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C H A P T E R S I X

Eyelids and

Lacrimal System

Blepharitis

Blepharitis is an inflammation of the eyelids. Several rows of oil glands run along the rims or margins of the eyelids in the area where the lashes begin. When these glands become irritated or inflamed, they produce extra oily, greasy material that becomes deposited on the eyelid margins and may get into the eye. The pores of the oil glands may also become plugged up. This plugging irritates the oil glands further, and a vicious cycle is created.

Blepharitis can be one of two types, or a combination: seborrheic, which may be associated with dandruff of the scalp or eyebrows; or staphylococcal, in which the glands harbor a low-grade infection that may flare up from

time to time. Blepharitis is a chronic condition that may be very difficult to clear up. It is probably the single most common medical eye problem for which people see their ophthalmologists.

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Copyright 2001 by Jay B. Levine. Click Here for Terms of Use.

T H E E Y E C A R E S O U R C E B O O K

Symptoms of Blepharitis

People who have blepharitis may experience any of the following symptoms: eye irritation, redness, tearing, feeling of something in the eye, itching, burning, occasional sharp pains, ache in or around

the eye, sensitivity to light, blurring, “film” over the eye, crusting or mattering at the base of the eyelashes, and frequent stye or chalazion formation. (See“Chalazia and Styes,”

page 64.) The symptoms may be most noticeable upon awakening, because the eyes have been bathing in the irritating secretions of the oil glands all night.

During the day, these secretions are partially washed away by the blinking of the eyelids and the flow of tears. Some of the symptoms of blepharitis may also be caused by other eye problems, such as dry eye syndrome or allergic problems. Many people actually have both dry eye syndrome and blepharitis at the same time.

Causes of Blepharitis

The excess oil that gets into the eyes causes most of the symptoms of blepharitis. The oil and other components of the oil gland secretions have a direct irritating effect on the cornea. Cells on the surface of the lower part of the cornea, which is often bathing in these secretions, can slough off. The excess oil also creates a chemical imbalance in the tear film. This chemical imbalance results in an unstable tear film. This means that the tears cannot coat the surface of the eye very well. Normally, the tear film on

the surface of the cornea should remain intact for at least ten seconds after a blink has spread fresh tears over the eye. But with

an unstable tear film, dry spots appear quickly, sometimes just one second after blinking. The process is similar to water beading up on a piece of wax paper. These dry spots are very irritating to the cornea and can cause sharp, needlelike pains. They can also cause blurring of vision, which is most noticeable during reading. When you read, you develop a little bit of a stare, and your eyes may blink only about half as often as they normally do. This

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gives those dry spots more time to form. Such blurring may be the only symptom of blepharitis.

Who Gets Blepharitis?

Blepharitis occurs most often in people who have oily skin. Diabetics may have a slightly higher risk of developing the problem. Some people have an underlying condition of the face called acne rosacea, or just rosacea for short. They tend to have tiny reddish bumps and corkscrewy blood vessels on the “blush” areas of the face. The skin changes are often most prominent on the nose. People with rosacea are very prone toward blepharitis, especially the staphylococcal type. Treatment of their underlying rosacea problem by a dermatologist can often help their blepharitis as well.

Problems Caused by Blepharitis

With the staphylococcal form of blepharitis, a wide variety of unusual problems may develop. The skin by the outer corner of the eye, where the eyelids meet, can become red and weepy in appearance, a condition called angular blepharitis. Sometimes the skin of the entire

eyelids, especially the upper eyelids, develops this red, weepy appearance, called eczematoid blepharitis because it resembles the common

allergic skin condition called eczema. Eczematoid blepharitis is felt to be a “hypersensitivity” or allergic type of reaction to the by-products of the bacteria that live in the oil glands.

Another type of hypersensitivity reaction is the marginal hypersensitivity ulcer. This is a whitish area that appears just under the surface of the cornea but not far from its edge, right where the margin of one of the eyelids crosses the cornea. The corneal epithelium, the surface layer of cells, then breaks down, forming a shallow ulcer. If you ever see a white spot on your cornea, have it checked out right away. You may have the beginnings of an ulcer.

Episcleritis, a condition in which the deeper blood vessels in one part of the eye become inflamed and engorged with blood (see “Episcleritis,” page 101, in chapter 7), is another type of hypersensitivity reaction occasionally seen in people with staphylococcal blepharitis. Even less common is phlyctenular

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conjunctivitis, in which a whitish nodule or bump appears at the edge of the cornea, with redness of the eye confined to that area.

Prompt treatment of blepharitis is important, particularly with the staphylococcal type, because otherwise a chronic infection may ensue as the bacteria become more deeply entrenched, making later eradication more difficult. With chronic infection, scarring may cause thickening of the eyelid margins, along with turning in or turning out of the eyelids and eyelashes.

Treating Blepharitis

The mainstay of treatment is known as lid hygiene or lid scrubs. First, apply warm compresses to the lids. To do this, hold a warm, moist washcloth against the closed eyelids, rewetting the washcloth with warm water every thirty seconds or so to keep it warm enough. Continue the warm compresses for about two minutes. Then take some mild baby shampoo that has been diluted about 50 percent with warm water, moisten a cotton-tipped applicator, and gently scrub the eyelid margins clean by wiping back and forth along their length, especially around the base of the eyelashes. This should include the upper and lower eyelids of both eyes if possible. The upper eyelids are more difficult, but by pulling up on the skin of the lid, you can often get the margin of the

eyelid to pull away from the eye a bit. If the diluted baby shampoo seems too irritating, dilute it even more with water. The lid scrubs may be done anywhere from once a day (gen-

erally at bedtime) up to four times a day, depending on the severity of the condition. After completing a scrub, rinse the eyelids gently with warm water.

The margin of the eyelid gets all the attention. The goal is to remove oily material from the lid margin so that it will not get into the eye and so that the oil glands will become unplugged. Makeup such as eyeliner on the lid margins can often aggravate the condition, however. Makeup should be confined to the eyelashes and to the skin side of the eyelids.

Seborrhea of the scalp, more commonly known as dandruff, frequently accompanies seborrheic blepharitis. Clearing up scalp dandruff by using a good dandruff shampoo often helps relieve the symptoms of blepharitis.

There is some evidence that a high-cholesterol, high-fat diet may worsen the oil gland problems and increase the secretion of oils into the tear film.

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Therefore, following a low-fat, low-cholesterol diet may have beneficial effects in people who suffer from blepharitis, just as it has beneficial effects with regard to so many other medical conditions.

In some cases, especially when staphylococcal blepharitis is present, a sulfa or antibiotic eye ointment is prescribed. The ointment should be applied very sparingly along the margin of the lower eyelids. A cotton-tipped applicator works well for this, or you can use your fingertip, assuming that your nails are short and you’ve just washed your hands. The ointment is applied after the lid scrub routine. If you use too much ointment, it blurs your vision. If the ointment is prescribed for once-a-day use, it is usually best to apply it at bedtime, when you won’t notice the blurring. In some cases, the ointment may be prescribed for up to six weeks at a time. In more resistant cases, a combination antibiotic and corticosteroid (cortisone) ointment is prescribed for limited periods of time. You should not use this type of ointment on your own without a physician’s advice because of the possibility of complications, especially with prolonged use.

You may wonder why antibiotic medication is sometimes used not only for the infectious staphylococcal form of blepharitis but also for the noninfectious seborrheic form. The reason is that although seborrheic blepharitis does not represent a true infection, there is often an overgrowth of bacteria in the affected oil glands, and these bacteria play a role in how these oil glands function. Suppressing these overgrown bacteria with medication can often make the glands function more normally and thereby quell the blepharitis. Dermatologists use the same principle to treat acne. In fact, antibiotics such as tetracycline and erythromycin are sometimes prescribed as a last resort, to be taken by mouth just as they are for acne.

If any of the hypersensitivity or allergic types of reactions, such as episcleritis, eczematoid blepharitis, phlyctenular conjunctivitis, or marginal hypersensitivity ulcer, is present, then special treatment, which usually includes the application of corticosteroid medication, may be needed. Again, such medication is available by prescription only.

Symptomatic treatment with over-the-counter artificial tear drops can be very helpful. These drops not only relieve irritation but also can help stabilize an unstable tear film that causes blurring and discomfort. The best drops for this purpose are the preservative-free ones, which come in tiny single-use plastic containers. The preservatives in regular artificial tear drops can irritate and

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even be toxic to the eye if used too frequently. If you have difficulty reading because of dry spot formation on the eye from an unstable tear film, you can use the drops every fifteen minutes if necessary. Try the different available brands and see which works best for you.

Although blepharitis is often a chronic, recurring condition, you can usually control the symptoms and prevent any complications just by keeping up with the lid hygiene routine. Additional treatment is generally reserved for flare-ups.

Chalazia and Styes

A chalazion, also known as an internal hordeolum, is a blockage of the pore of one of the oil glands that line the margins of the eyelids. The oil gland becomes “angry” when this happens, and it and the surrounding eyelid tissue become quite inflamed. At first, there may be pain in the area, along with mild redness and some diffuse swelling. After a few days,

the swelling becomes more localized, forming a small “knot” in the area of the oil gland. In a small percentage of cases chalazia become infected, usually by a bacterium called staphy-

lococcus. If that occurs, the swelling and redness become more intense, and the lymph node in the area of drainage from the lid becomes enlarged.

For the upper lid, the lymph node is located just in front of the ear on that side, whereas for the lower lid, the lymph node is just under the angle of the jaw. Lymph nodes contain tissue that helps the body fight infection.

A stye, also known as an external hordeolum, is a cousin to a chalazion. It represents an abscess of a more superficial type of gland. Whereas a chalazion points toward either the skin or the underside of the eyelid, a stye points toward the margin of the eyelid, where its inflamed whitish head can be seen.

Who Gets Chalazia and Styes?

The people who are most prone to develop chalazia and styes are those who suffer from chronic blepharitis, an inflammation of the oil glands of the eyelids. (See “Blepharitis,” page 59.) Blepharitis causes the oil glands to become overactive and to secrete a thick oil that can plug up the pores of the oil glands.

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Therefore, for people who develop recurrent chalazia or styes, the best preventive measure is often to treat the underlying chronic blepharitis.

Treating Chalazia and Styes

The initial treatment for chalazia and styes is warm compresses. Wet a washcloth with water as warm as can be tolerated and then hold it against the area of the chalazion for ten minutes. Rewet it frequently during this period to keep it warm all the time. Perform this routine at least four times a day, more frequently if possible. It may be difficult to find

time during the day to do this, but it really pays off. Use the warm compresses until the chalazion or stye is gone, usually for at least a

week but sometimes for several weeks. Application of antibiotic or similar ointments has never been shown to be of value in treating chalazia and styes.

If you have been using the warm compresses for a week or two but a welllocalized chalazion is still present, an additional procedure can be performed. The ophthalmologist can inject a small amount of corticosteroid (cortisone) liquid into the chalazion with a very tiny needle. Injecting the liquid in this manner may build up enough pressure in the chalazion to force open the blocked-off pore, leading to a quick resolution of the problem. Even if this does not happen, the medication itself has an anti-inflammatory effect that can speed up the healing process. A single injection such as this usually has about a 50 percent success rate. Following the injection, continue the warm compresses until the chalazion appears completely gone.

If, after two to four weeks, the chalazion shows no sign of going away, we usually drain it, a minor surgical procedure. Some ophthalmologists perform the surgery much earlier than this, as soon as the chalazion becomes localized, but I think it is best to avoid even minor surgery, if possible.

The surgery should be performed under sterile conditions. The skin of the eyelids is wiped with an antiseptic solution such as povidone iodine, and a sterile plastic drape with a hole in the center is placed around the eye. The eyelid is then numbed by drops in the eye and a small injection of local anesthetic such as lidocaine under the skin of the eyelid. The eyelid is everted (turned over on itself), and a special clamp is applied to the lid to hold it in place. A small X-shaped incision is then made directly into the chalazion through the

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underside of the eyelid. The creamy contents of the chalazion are evacuated, and its interior is scraped to prevent recurrence. The opening into the eyelid is then enlarged so that the chalazion can continue to drain. The eye is generally left unpatched, and the warm compresses are resumed beginning the next day and continued until no sign of the chalazion remains. The surgery is usually curative.

In the unusual event that the chalazion becomes infected, antibiotic treatment by mouth generally becomes necessary. Otherwise, a periorbital cellulitis, a dangerous infection involving the entire eyelid, may develop, along with the possibility that it might spread to the orbit. Fortunately, infected chalazia usually respond quickly to appropriate antibiotic treatment accompanied by continued warm compresses.

Dry Eye Syndrome

The Importance of Tears

Drying out can be an ecological disaster for the environment, and the same is true for our eyes. The tears not only provide protection and comfort for the surface of our eyes but also are essential for good vision. To understand how dry eye syndrome can affect the eyes, we must first look at the nature of tears and the role they play in keeping the eyes healthy.

What Is the Tear Film?

To function normally, the cornea (front surface of the eyeball) must be covered at all times by a coat of tears called the tear film. This tear film consists of three distinct layers. Sandwiched in the middle is a watery layer produced by the main tear gland, located under the outer

portion of the upper eyelid, and by many tiny tear glands, located all along the inside surface of the lid. The outermost layer of the tear film is an oily layer that helps keep the tears from evaporating. The oil is produced by glands near

the margins of both the upper and lower eyelids. Finally, the innermost layer, the one that touches the eye itself, is composed of a substance called mucin,

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produced by mucus glands in the eyelids. The mucin acts as a detergent: It allows the tears to spread smoothly and evenly over the front surface of the eye. If this layer were not present, you would have an unstable tear film: The tears would bead up on the eye, and dry spots would be present between these watery islands. It would look very similar to what you see when water is sprayed on a car that has just been waxed.

What Is Dry Eye Syndrome?

There are two major types of dry eye syndrome, although many people actually have a combination of the two. The first is the aqueous deficiency form of dry eye syndrome. With this type, the tear glands are simply not making enough tears, so the middle, watery layer of the tear film thins out. Examination of the eye reveals a low level of tear fluid above the rim of the lower eyelid. A Schirmer test, in which a thin strip of special paper is hung over the edge of the lower eyelid and the amount of wetting achieved over five minutes is measured, can also be helpful in the diagnosis. Finally, special dyes can be instilled in the eye to show whether cells on the surface of the eye are sloughing off because of dryness.

Common symptoms include burning, irritation, itching, feeling of something in the eye, and light sensitivity. For many people, difficulty reading for more than a few minutes at a time may be the only symptom. In addition, many people with dry eyes complain of tearing—not

what you might expect! Because of the dryness, the tear gland occasionally puts out a spurt of tears, and that’s where the tearing comes from. Symptoms tend to be more marked in people

living in hot, dry climates. Aging is the most common risk factor for aqueous deficiency, but other risk factors include rheumatoid arthritis, lupus, Sjögren’s syndrome, scleroderma, hypothyroidism (underactive thyroid gland), and estrogen deficiency, as with menopause or following total hysterectomy with removal of the ovaries. Most people, however, have no underlying disease.

The other form of dry eye syndrome is the unstable tear film type. This results in dry spot formation on the eye, as noted before. Every time you blink, a fresh coat of tears is swept over the surface of the eye. Therefore, we can diagnose an unstable tear film by measuring how long it takes after a blink for dry

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