Natural history
- Blepharitis
- Chronic, with periods of exacerbation and remission
- Can begin in childhood, although typically onset is in middle age
- If severe, can cause eyelash loss, scarring of eyelids, trichiasis, secondary corneal scarring
- Chalazia
- Typically self-limiting, resolving in 1–2 weeks
- Chronic form may develop which can take many months to years to resolve.
- Eventually, virtually all chalazia resolve, even after years (Honda 2010).
Medical therapy
Blepharitis
- Eyelid hygiene
- Warm compresses
- Scrubs with water, dilute baby shampoo or commercially available eyelid wipes once or twice daily depending on severity
- Olenik study (Olenik 2013):
- Randomized double-blinded trial of baby-shampoo eyelid cleaning and preservative-free artificial tears with placebo or 1.5 gram of a composition (DHA, EPA, vitamins A, C, and E, tyrosine, cysteine, glutathione, zinc, copper, manganese, selenium, DPA)
- Measurements of staining, tear breakup time, Schirmer test, eyelid inflammation, ocular surface disease index (OSDI), meibomian gland expression
- After 3 months (64 patients), there was significant improvement of OSDI, TBUT, eyelid margin inflammation, meibomian gland expression, Schirmer test.
- For staphylococcal blepharitis treat with topical antibiotics, for example, erythromycin or bacitracin ophthalmic ointment
- Topical azithromycin ophthalmic solution 1%
- Has anti-inflammatory properties
- Studies have shown improvement for anterior and posterior blepharitis — open label studies (John 2008, Luchs 2008, Haque 2010, Opitz 2011).
- Dosing schedules are varied - 1 gtt BID x 2 days, then qday for 7–28 days (Opitz 2012)
- A multicenter, randomized study comparing Tobradex ST (4x/day x 14 days) to Durasite (2x/day x 12 days) for blepharitis favored Tobradex (Torkildsen 2011)
- Ivermectin cream 1% can reduce demodecosis (Favier, 2017)
- Ivermectin can be administered orally at a dose of 200 mcg/kg once, repeated in 7 days
- Reduces demodex folliculorum in refractory blepharitis (Holzchuh, 2011)
- Available as 3 mg tablet - 170 lb. (77 kg) adult would take 15 mg or five pills
- Minocycline or doxycycline 50–100 mg BID can be considered for chronic meibomitis
- Can taper to qday after the first month
- Slow-release formulation (50 mg qday) might be effective
- Alternatives include tetracycline 500 mg BID or azithromycin 250–500 mg, 1–3x/week; or 1g qweek x 3 weeks (caution in patients with cardiac conduction abnormalities)
- Treatment based on small clinical trials on symptoms improvement with ocular rosacea (Frucht-Pery 1993, Sobolewska 2014)
- Evidence of improving blepharitis symptoms (Dougherty 1991, Shine 2003)
- Short course of topical corticosteroids can be used when inflammation is severe.
- Eyelid thermal pulsation system (LipiFlow)
- Device uses pulsatile "milking" movements and application of heat to each eyelid
- A single treatment (12 minutes) can have improvement in ocular surface disease index (OSDI).
- Has been shown to be more effective than heat (warm compresses) alone
- No randomized controlled studies
Meibomitis
- 150 patients with clinical evidence of meibomitis were randomized into three groups, treated for one month with doxycycline 200 mg BID, doxycycline 20 mg BID, or placebo (Yoo, 2005).
- The study did not assess lid changes.
- Both treatment groups had improvement in tear breakup time and Shirmer test, compared with placebo.
- Quaterman reported improvement in eyelid inflammation at 12 weeks in open label trial of doxycycline 100 mg daily for 12 weeks (Quaterman, 1997).
- Aronowicz (2006) treated 16 meibomitis patients with 50 mg minocycline daily for 2 weeks, followed by 10 weeks of 100 mg daily.
- Assessed appearance of the eyelids, degree of meibomian gland plugging and amount of secretion
- Noted improvement in eyelid margin thickening and vascularization
- Decrease in eyelid margin debris and less meibomian gland obliteration
- Effect continued three months after cessation of the medication.
- Igami (2011) treated 13 meibomitis patients who had not responded to topical corticosteroids and antibiotics with oral azithromycin.
- In 3 cycles of 500 mg/day for 3 consecutive days at 7-day intervals
- Using eyelid scoring system that measured severity of eyelid debris, telangiectasias, mucous secretion, and eyelid margin edema and erythema
- Found clinical improvement, except eyelid edema, thirty days after completion of therapy
- Once weekly azithromycin, 1 gram orally for three weeks, was assessed in 32 patients with meimobitis, using subjective improvement as the primary end point (Greene, 2014).
- Concurrently continued treatment with topical steroid drops and compresses
- At mean 5 week follow-up 75% reported symptomatic improvement
- GI upset was the most common side effect (9%)
- Literature assessment by the American Academy of Ophthalmology concluded that there is no level I evidence to support use of oral antibiotics including doxycycline, minocycline or azithromycin for meibomian gland related ocular suface disease (Wladis, 2016).
Chalazia/Hordeola
- Warm compresses and eyelid massage
- Eyelid hygiene/scrubs
- Topical antibiotics may be of value in treating staphylococcal blepharitis component.
- Systemic antibiotics are active against Staphylococcus aureus for accompanying preseptal cellulites.
- Systemic tetracyclines for treatment of chronic accompanying meibomitis, rosacea
- Topical or systemic tetracyclines can help improve meibomian secretions.
- Topical steroid can be used to decrease inflammatory component of skin (although not demonstrated in any studies).
Surgery
Blepharitis
- Intraductal meibomian probing (that is, Maskin probe) (Maskin 2010)
- Topical anesthetic or injected local anesthetic placed into the eyelid
- Start with 2-mm probe (Figure 2)
Figure 2. Maskin probe usage. Penetration through orifice with 2-mm probe. Note hemorrhage at orifice of adjacent gland.
- Can encounter resistance at meibomian gland orifice and within gland (fibrovascular tissue)
- Normal to have droplet of blood at orifice
- Then repeat with 4‑mm probe
- Can be also done with hyfrecation tip (Figure 3) (Wladis 2012)
- Anatomic changes resulting in trichiasis or entropion might require surgical correction.
Figure 3. Meibomian probing. Image courtesy Edward J. Wladis, MD.
Chalazia/Hordeola
- Intralesional/perilesional corticosteroid injection
- Can be used for small marginal lesions or other lesions
- Multiple randomized controlled studies assessing injection versus excision (Ben Simon 2011, Goawalla 2007, Jacobs 1984)
- Can have similar rates of resolution, although Jacobs reported much higher rate of complete resolution with surgery (60% versus 8.7%)
- Multiple injections may be needed
- Can use 40 mg/mL or 10 mg/mL triamcinolone and inject 0.05 to 0.15 cc
- Most studies do not use a chalazion clamp at time of injection.
- Surgical drainage via a transconjunctival or cutaneous route
- Anesthetic
- Especially with small lesions, consider marking the skin prior to injection; otherwise, the location of the chalazion can be masked after infiltration.
- Consider using a pledget with 4% lidocaine (plain) between the globe and chalazion to help dull the pain of injection.
- Incision and curettage
- Chalazion clamp is placed on the eyelid to isolate the chalazion, and the eyelid is everted.
- Bard Parker #15 or #11 blade is used to make a stab incision through the posterior tarsal plate.
- Can be vertical or an "x;" some surgeons excise the flaps of the "x;" others leave them.
- Liquid and gelatinous material is expressed.
- Curettage can be performed with a chalazion curette.
- Excise granulomatous tissue and cyst wall especially in chronic forms with little or limited liquid/gelatinous material
- Caution to prevent violation of the skin.
- Cutaneous excision
- In cases of cutaneous changes (erythema, infiltration, thinning), limited excision of skin might be needed to resolve the lesion.
- Use caution in dark-pigmented patients because the visible scar can be more pronounced.
- Because the source of the chalazion is in the tarsal plate, this must also be addressed in addition to the skin.
- Trephination
- Through the conjunctival surface, a "punch" biopsy trephine can be used (Leachman).
- With the trephine (2–5 mm diameter), center it over the visible lesion, and then slowly rotate the trephine while applying pressure.
- Be careful to prevent penetration past the tarsal plate.
- Once through the full thickness of tarsus, use scissors and forceps to excise.
- Margin lesions
- Some suggest marginal curettage (Dubey).
- After placement of an appropriately sized clamp, the curette is placed into the chalazion and curetted.
- The remainder of the proximal chalazion is approached in the "standard" fashion.
- Care should be taken not to communicate the 2 areas to prevent notching.
- Combined excision and corticosteroid injection
- After excision is completed, some authors advocate for intratarsal injection of steroid.
- Best done with clamp in place to prevent embolization of steroid material
- Biopsy for recurrent or atypical lesions
- Caution for any atypical lesions in either appearance or history
- Concern for malignancy or other atypical lesions