Chronische Blepharitis

Developing and validating a questionnaire to assess the symptoms of blepharitis accompanied by dry eye disease

PURPOSE

To propose additional items for established dry eye disease (DED) instruments that cover blepharitis-specific signs and symptoms and to determine the association between the clinical findings and subjective complaints.

METHODS

Thirty-one patients with blepharitis and DED were prospectively included in the pretest period for selecting suitable questions. In the main phase of the study, the selected questions were then tested on 68 patients with blepharitis and DED and 20 controls without blepharitis or DED. Pearson's coefficient of correlation was calculated between the blepharitis-specific questions, tear break-up time (TBUT), the Schirmer test score, and the ocular surface disease index (OSDI) score; and the similarity between the blepharitis-specific questions, OSDI questions, and objective parameters for DED was assessed via hierarchical clustering. Furthermore, the discriminatory power of the blepharitis-specific questions was investigated with the receiver operating characteristic (ROC) curve.

RESULTS

The additional question about heavy eyelids revealed a significant correlation with the OSDI score (r = 0.45, p < 0.001) and Schirmer score (r =  - 0.32, p = 0.006). Cluster analysis demonstrated the similarity between the question about heavy eyelids and TBUT. In addition, the OSDI questionnaire had the highest discriminatory power in ROC analysis, and the OSDI score significantly correlated with the specific questions about eyelids sticking together (r = 0.47, p < 0.0001) and watery or teary eyes (r = 0.34, p = 0.003).

CONCLUSIONS

The blepharitis-specific additional questions were closely associated with objective parameters for DED. The question about heavy eyelids might be well suited for recording the symptoms of hyposecretory and hyperevaporative dry eye with blepharitis.

The role of environment in the pathogenesis of keratoconus

PURPOSE OF REVIEW

This study was conducted to demonstrate the importance of the environment in keratoconus (KC) genesis.

RECENT FINDINGS

Genetic-related connective tissue disorders demonstrate the inconsistency of theories regarding KC pathogenesis since no corneal steepening was observed in the majority of these patients. Despite recent advances and decades of research into the genetics of KC, the identification of disease-causing KC genes has been frustrating. Variants found based on genome-wide and next-generation sequencing only seem to account for a small number of cases or play a limited role in KC pathogenesis.

SUMMARY

The literature shows that mechanical manipulation may be the common underlying factor or the indispensable act precipitating the cascade of events leading to permanent corneal deformation. Hence, ophthalmologists have the opportunity to increase patient awareness about eye manipulation repercussions and treatment for ocular surface disorders.

VIDEO ABSTRACT

http://links.lww.com/COOP/A42.

Prevalence and antibiotic susceptibility of bacteria isolated in patients affected with blepharitis in a tertiary eye centre in Spain

PURPOSE

To describe which bacteria can be found on lid margins in patients affected with blepharitis, to show their antibiotic susceptibility pattern, and to evaluate the antibiotic resistance trend of coagulase-negative Staphylococcus through time.

MATERIALS AND METHODS

Consecutive cases of 198 eyes affected with blepharitis between 2012 and 2018 were reviewed. A sample was collected by rubbing a swab against the base of the eyelashes of both the eyes of all patients. The samples were inoculated in blood agar and chocolate agar. The susceptibility of the identified bacteria to common antibiotics was tested. In addition, the antibiotic susceptibility pattern of coagulase-negative Staphylococcus detected from year 2016 to 2018 was compared with that of 4 years before.

RESULTS

The most common isolated bacterium was coagulase-negative Staphylococcus (89%) and Staphylococcus aureus (28%). Coagulase-negative Staphylococcus showed highest susceptibility to vancomycin (100%), neomycin (94%) and chloramphenicol (91%). Coagulase-negative Staphylococcus and Staphylococcus aureus were the most resistant to penicillin and erythromycin (resistance in 92%, 91% for coagulase-negative Staphylococcus, 86% and 43% of eyes for Staphylococcus aureus). Corynebacterium was resistant to oxacillin and erythromycin. Streptococcus viridans showed resistance to gentamycin and tobramycin. Moraxella was susceptible to most antibiotics. Bacillus was resistant to oxacillin. The antibiotic resistance trend of coagulase-negative Staphylococcus showed that the resistance to rifampicin increased through the years 2012-2018.

CONCLUSION

Coagulase-negative Staphylococcus and Staphylococcus aureus were the most isolated bacteria in patients affected by blepharitis in our tertiary eye centre. Both bacteria were resistant to erythromycin. Through the years, it seems that coagulase-negative Staphylococcus gained resistance to penicillin, erythromycin, ciprofloxacin and rifampicin.

[Blepharitis component of dry eye syndrome]

This review contains a compilation of long-standing and more recent relevant information on chronic blepharitis, especially in the context of dry eye disease regarding epidemiology, symptoms, clinical findings and pathophysiology. Chronic blepharitis often represents the underlying cause of dry eye disease but remains undetected and untreated in many cases; however, it can be a result of (hypovolemic) dry eye disease and leads to sometimes severe corneal complications, which are illustrated by material from our own patient archives. Recent findings regarding the lipid composition in the tear film in correlation with that of Meibomian gland secretions and the hypothesis of a biofilm as the basis of chronic blepharitis as a theoretical, not yet proven addition to the previously known pathophysiological factors, are discussed.

TFOS DEWS II pathophysiology report

The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.

Medical Management of Blepharokeratoconjunctivitis in Children: A Delphi Consensus

PURPOSE

To describe a pragmatic approach to the medical management of blepharokeratoconjunctivitis in children, based on published evidence and clinical experience.

METHODS

The authors used the Delphi consensus method to explore the preferred management patterns of four senior clinicians at one institution to reach agreement on indications and dosage schedules for commonly used treatments. Four iterations were created, with electronic questionnaires distributed via an online survey platform. Initial questions were based on recent systematic reviews and clinical experience. After each round, a facilitator summarized the responses and fed these back to the expert participants, together with an invitation to complete the next round of questions.

RESULTS

Typical and specific eyelid, corneal, and conjunctival disease features influenced management decisions, and treatments were targeted toward specific findings in these tissues rather than to overall disease severity. Active keratitis was considered the main indication for high potency steroids, systemic antibiotics, and possibly systemic immunomodulators. Other indications for systemic antibiotics were chronic active blepharitis and recurrent troublesome chalazia. Oral antibiotics were used for their anti-inflammatory and antimicrobial properties. There was little agreement on the role of dietary modification, topical lubricants, and preference for oral or topical antibiotics.

CONCLUSIONS

Detailed clinical assessment of eyelids and ocular surface allows targeted treatment. Research is needed to clarify disease mechanisms and to optimize treatment strategies. [J Pediatr Ophthalmol Strabismus. 2017;54(3):156-162.].

[Treatment options for chronic blepharitis considering current evidence]

The goal of the treatment of chronic blepharitis lies in the reduction of inflammation, which can be achieved by warming, mechanical, and immunomodulatory measures as well as acaricide medication in cases with pathogenetically relevant demodicosis.

A randomized, double-masked, parallel-group, comparative study to evaluate the clinical efficacy and safety of 1% azithromycin-0.1% dexamethasone combination compared to 1% azithromycin alone, 0.1% dexamethasone alone, and vehicle in the treatment of subjects with blepharitis

Purpose

To evaluate the clinical efficacy and safety of a 1% azithromycin–0.1% dexamethasone combination in DuraSite (“combination”) compared to 0.1% dexamethasone in DuraSite, 1% azithromycin in DuraSite, and vehicle in the treatment of subjects with blepharitis.

Materials and methods

This was a Phase III, double-masked, vehicle-controlled, four-arm study in which 907 subjects with blepharitis were randomized to combination (n=305), 0.1% dexamethasone (n=298), 1% azithromycin (n=155), or vehicle (n=149). Ten study visits were scheduled: screening visit, days 1 and 4 (dosing phase) and 15, and months 1–6 (follow-up phase). On day 1, subjects applied one drop of the study drug to the eyelid of the inflamed eye(s) twice daily, and continued with twice-daily dosing for 14 days. After completing 14 days of dosing, subjects were followed for 6 months for efficacy and safety.

Results

A total of 57 subjects (6.3%) had complete clinical resolution at day 15: 25 (8.2%), 17 (5.7%), 8 (5.2%), and 7 (4.7%) subjects in the combination-, 0.1% dexamethasone-, 1% azithromycin-, and vehicle-treatment groups, respectively. The combination was superior to 1% azithromycin and vehicle alone, but not to 0.1% dexamethasone alone. Mean composite (total) clinical sign and symptom scores improved in all four treatment groups during the post-treatment evaluation phase for the intent-to-treat population, but outcomes were superior when a drop containing 0.1% dexamethasone was utilized. Clinical response was noted as early as day 4, and persisted as long as 6 months. Most adverse events were considered mild in severity and not related to the study drug.

Conclusion

A higher percentage of subjects in the combination group achieved complete clinical resolution of the signs and symptoms of blepharitis at day 15 than with 1% azithromycin and vehicle, but outcomes were similar to treatment with 0.1% dexamethasone alone. The combination was well tolerated.

Evaluation of Meibomian Gland Dysfunction and Local Distribution of Meibomian Gland Atrophy by Non-contact Infrared Meibography

AIMS

The main purpose of this study was to investigate the relationship between Meibomian gland atrophy (meiboscore) and Meibomian gland expressibility. In addition, the local distribution of Meibomian gland loss was analyzed.

METHODS

A retrospective analysis of 128 patients (92 women and 36 men, 57 ± 17 years) from our dry eye clinic was performed. Infrared meibography was performed using the Keratograph 5 M (Oculus, Wetzlar, Germany) and evaluated with a scoring system introduced by Arita et al.

RESULTS

A significant inverse correlation between Meibomian gland atrophy measured by meibography and expressible Meibomian glands (r = -0.197, p = 0.003) as well as between meiboscore and TBUT (r = -0.1615, p = 0.012) was found. There also was a significant correlation between the total meiboscore and the age (r = 0.33, p < 0.0001). We could find a strong and highly significant correlation between the total meiboscore and the individual meiboscore of the upper eyelid (r = 0.905, p < 0.0001) and the lower eyelid (r = 0.892, p < 0.0001). There was no significant difference of Meibomian gland atrophy between the individual thirds of the upper eyelid, but for the lower eyelid, we could find a higher degree of Meibomian gland atrophy in the nasal third compared with the middle and the temporal third (Dunn's post hoc test, p < 0.0001).

CONCLUSIONS

Meibomian gland atrophy seems to be not constant over the tarsal plate but the examination of the lower tarsus might be sufficient in most of the cases. The correlation of the meiboscore with functional dry eye parameters suggest that in patients with detectable Meibomian gland atrophy there is also an impaired Meibomian gland function. However, meibography seems not to be sufficient as a single test for the diagnosis of MGD. For the future larger, prospective studies are needed to confirm these results and further evaluate the potential of meibography in the diagnosis of MGD.

[Contact lens associated dry eye. Current study results and practical implementation]

Contact lens-associated dry eye symptoms have mostly been therapeutically addressed using artificial tears containing hyaluronic acid to supplement tear film volume with often unsatisfactory results. However, the main reason for contact lens-associated dry eye is not the lack of tear fluid but the lack of tear film stability due to meibomian gland dysfunction leading to reduction of the lipid film of tears. This is associated with increased evaporation of the aqueous phase of tear fluid and a measurable hyperosmolarity of the residual "denatured" tear film. A subsequent inflammatory reaction of the ocular surface then leads to the vicious circle of dry eye. The aim of this review is to summarize current study results on this topic and to give practical advice on how to address dry eye symptoms in contact lens wearers more accurately. For most contact lens-associated dry eye symptoms a combined therapy with unpreserved artificial tears plus phospholipid-liposome eye spray yields the best results. In cases of additional signs of blepharitis the regular use of phospholipid-liposome solution for lid margin hygiene is beneficial.

[Testosterone reduces the expression of keratinization-promoting genes in murine Meibomian glands]

BACKGROUND

Extensive keratinization appears to play a major role in the dysfunction of the Meibomian gland. This article presents the potential impact of androgens on limiting keratinization in this tissue, thus, contributing to normal Meibomian gland function and a healthy ocular surface.

MATERIALS AND METHODS

Orchidectomized mice were systemically treated with either testosterone or placebo for 2 weeks. The mRNA was then extracted from the Meibomian glands and differential gene expression was investigated by microarray hybridization and evaluation with GeneSifter software as well as gene ontology information from the Gene Ontology (GO) Consortium.

RESULTS

By z-score calculations, keratinization was the most significantly gene ontology term influenced by testosterone based on down-regulated genes in the mouse Meibomian gland. In particular, under the influence of testosterone the genes coding for small proline-rich protein (Sprr) 2a, Sprr 2b, Sprr 3, keratins 6a and 17 and periplakin were significantly down-regulated, while Sprr 1a and Sprr 2f were significantly up-regulated.

CONCLUSIONS

Testosterone down-regulates the expression of genes promoting keratinization in the Meibomian gland. This may help to prevent Meibomian gland dysfunction by limiting excessive keratinization of this tissue and the adjacent lid margins. The findings elucidate, at least in part, the beneficial impact of androgens on Meibomian gland function and thus on th e health of the ocular surface.

Disruption and destabilization of meibomian lipid films caused by increasing amounts of ceramides and cholesterol

PURPOSE

We evaluated quantitatively direct effects of ceramide (Cer) and free cholesterol (FC) on meibomian lipid films (MLF) using a Langmuir trough (LT) and a Brewster angle microscope (BAM).

METHODS

Meibum was obtained from healthy volunteers. A series of mixtures of meibum with Cer or FC (mixed MLF) taken in different ratios were tested. Standard rheologic parameters, such as elasticity and hysteresis of MLF, were computed. BAM was used to study the morphology of MLF.

RESULTS

Pure MLF were capable of withstanding multiple compression/expansion cycles with little hysteresis observed (1.9 J/G meibum). The films made of either pure CER or pure FC were clearly collapsible, and had much higher rigidity and hysteresis than pure meibum. Adding progressively higher amounts of CER or FC to meibum had a strong impact on the rigidity, stability, and morphology of the mixed MLF: their hysteresis increased many fold compared to pure meibum. A concomitant increase in the rigidity and collapsibility of the mixed MLF was observed.

CONCLUSIONS

Cer and FC changed the surface properties of mixed MLF in a way that implied their destabilization and/or disruption. One of the mechanisms that might lead to these effects is strong aggregation of meibum lipids with FC or Cer that leads to the formation of smaller particles of meibum surrounded by a thinner layer of FC or Cer. As Cer and FC can be elevated in meibum and the tear film because of certain pathologic processes, or can be of exogenous nature, our results can explain (partially) a less stable tear film in those subjects.

Immunohistochemical expression of epithelial cell markers in corneas with congenital aniridia and ocular cicatrizing pemphigoid

PURPOSE

We investigated the immunohistochemical characteristics of corneal specimens in congenital aniridia and pemphigoid using various corneal markers to determine the status of the corneal epithelium.

METHODS

Conjunctivalization was clinically suspected in all corneas. Ten aniridia and seven pemphigoid paraffin-embedded corneal specimens were stained with periodic Schiff reagent (PAS) and antibodies against CK3/12, CK12, CK19, breast cancer resistance protein 1 (BCRP) and p63.

RESULTS

Aniridia: six cases contained goblet cells, four were negative. Both groups had cases with (three of six; one of four) and without CK19 positivity and cases with (two of six; three of four) and without p63 positivity. All aniridia cases except two in the goblet cell group were CK3/12- and CK12-positive and BCRP-negative. Pemphigoid: only one of the seven cases contained goblet cells. This case stained positively for CK19, 3/12, 12 and p63 and negatively for BCRP. The other six cases were positive for CK3/12, five of which were positive for CK12; only one case was CK19-positive. Three cases were p63-positive and two BCRP-positive. The CK12 staining was heterogenous in most cases and was often found in the superficial layer.

CONCLUSION

Three different stages of epithelial characteristics were found in congenital aniridia and pemphigoid: (i) CK19-negative and inhomogenous CK12-positive cases indicating epithelium mainly from (partly) CK12-deficient limbal stem cells; (ii) CK19- and/or goblet cell-positive and CK12-positive cases with their epithelia originating from CK12-deficient limbal stem cells and from incursing conjunctival cells; and (iii) CK19-positive and CK12-negative cases consisting of conjunctival cells alone.

[Meibomian glands. Part I: anatomy, embryology and histology of the Meibomian glands]

The Meibomian glands are large sebaceous glands that are located as separate gland strands in parallel arrangement within the tarsal plates of the eyelids. Their oily product (meibum) is secreted by a holocrine mechanism during which the secretory cells (meibocytes) are completely transformed into the meibum after synthesis and accumulation of lipids. After production in the gland acini, meibum is transported through the ductal system via the connecting duct (ductule) and the central duct towards the orifice at the free lid margin close to the inner lid border. The embryological development of the Meibomian glands takes place during the differentiation of the eyelids in the sealing phase of the eyelids. They are not directly associated with hair follicles but share important similarities in embryology, structure and keratinization potency with the cilia. Similar to the sebaceous glands Meibomian glands are regulated via sex hormones and androgens have a supporting function whereas estrogens act antagonistically. However, in contrast to other sebaceous glands they also have a distinct innervation, apart from sympathetic and sensory primarily by parasympathetic fibers that share the innervation pattern of the lacrimal glands. The anatomy, embryology and histology of the Meibomian glands are explained here, mainly with respect to humans, in an extensive review.