Eyelid Therapy for DED Management

Question 1

Describe level 1: eyelid therapy for DED?

Answer 1

• Eyelid therapy
• DED is present in:
• 50% of people with staphylococcal blepharitis
   Dry, crusty, flaky, at base of eyelashes but run through length of eyelashes
  o 25-40% of people with seborrheic blepharitis
   Lashes clumped, more oily, more greasy, capped MGs & telangiectasia

Question 2

Describe how to explain bleph to px?

Answer 2

• Need to be careful not to give them the impression you are calling them dirty
• CMG:
  o “Bleph is a condition in which chronic inflammation of eyelid margins causes sxs of eye irritation”
  o “MGD results when condition affects inside rims of eyelids just behind lashes which contain MGs. MGs produce thin layer of oil which normally prevents tears from evaporating too quickly; if they are inflamed, this mechanism does not work properly”

Question 3

Describe hot compresses for eyelid therapy (DED)?

Answer 3

• Attempting to melt/soften meibum to then manually express glands
• Temp recommended is 40°C (temp of palpebral conj/glands)
• More severe the blockage, higher the temp required (45°C considered max to avoid thermal damage)
• Research divided on whether wet or dry compress will heat more effectively – wet can help soften crusts in anterior bleph
• On the market:
  o Multiple options with slight variations
  o Can contain different ingredients e.g. flax seed, silica beads, synthetic gel beads
  o Certain practices will stock their preferred option
  o Can require a microwave for heating
  o MGD Rx EyeBag was highlighted in DEWS II report
• Plug-in:
  o Blephasteam
   Plug in device that creates warm, humid environment around eye
   Paper insert in goggle that heats up & becomes moist – seals eye – replace paper each time
   Can be worn and watch TV for e.g.
   Good for px with chronic MGD who needs hot compress regularly – not interrupting life
   Theory is that it will maintain stable heat for duration of tx
   You wait 15mins for it to warm up then it will remain warm for 10mins
   £200 RRP

Question 4

Describe eyelid massage as eyelid therapy (DED)?

Answer 4

• Not enough just to melt meibum
• Need to encourage blockage out before it solidifies again
• Firm massage below lower glands & above upper glands on completion of hot compress
• Demo this with every px
  o Express glands on slit lamp to show px how much pressure to apply
• Can also be done in practice with forceps

Question 5

Describe lid cleansing as eyelid therapy (DED)?

Answer 5

• Commercial eyelid cleansing solution e.g. Ocusoft or Blephasol
• Commercial wipes
• Baby shampoo – not as common now
• Cooled boiled water
• Bicarbonate of soda – not as common now
• Technique:
  o Liken it to removing make up – people seem to understand this well
  o Demo in practice
   Px needs to understand technique – not just one swipe
  o Duration: 30 seconds per eye – depends on severity (longer if more severe)

Question 6

Describe compliance in eyelid therapy (DED)?

Answer 6

• Hard when don’t see instant results
• Inconvenient for px to constantly be doing eye hygiene – but very important
• Important communication
• No short dose of anything to fix this
• Chronic condition – needs constant management
• Explain reason why doing this – no instant fix

Question 7

Describe BelphEx for eyelid therapy (DED)?

Answer 7

• In practice lid hygiene
• Involves moving a rotating micro-sponge along lash margin – one sponge for each of 4 sets of lashes
• Should remove debris & exfoliate lid margin
• Manufacturers advise repeating every 4-6mths
• Still carry out daily lid hygiene at home
• Analogy of scale & polish at dentist (deep clean every 6mths but still brush teeth each day)
• Use eyelid cleansing solution along with this e.g. Blephasol

Question 8

Describe level 2: demodex (DED)?

Answer 8

• Demodex Folliculorum live in & around hair follicles i.e. eyelashes, around 0.3-0.4mm in length
• Demodex Brevis live deeper in sebaceous glands i.e. rosacea & MGD, around 0.2-0.3mm in length
• General consensus is that they can be harmless but an over-population or an immune compromised px can lead to sxs
• Sxs tend to be worse at night & on waking – demodex hate light
• Itching can be common sx
• Look for demodex in px who is not responding to standard anterior bleph tx
• Appearance:
  o Tail of D Follicullorum that looking for at base of lashes
  o 40x mag required
  o Look for cylindrical dandruff/ ‘volcanoes’/waxy debris at base of lashes that hasn’t responded to standard lid hygiene – ensure px has been compliant
  o The material will not grow along eyelash (unlike staphylococcal)
  o Using tweezers twist eyelash clockwise & anti-clockwise or laterally (towards you without epilating) right & left and in & out and tail can often emerge more clearly

Question 9

Describe demodex management?

Answer 9

• Demodex do not respond to standard lid hygiene, a miticidal (something that kills mites) is required
• Tea tree oil has been shown to miticidal – BUT is also toxic to ocular surface
  o In practice weekly tx of 50% tea tree oil – often mixed with another oil such as macadamia nut
  o Eye must be kept closed throughout – use a cotton bud (after thorough lid hygiene) to apply to base of lashes
  o This should be done by an experienced practitioner
• Specialist lid wipes/cleaners
• Contain various strengths of TTO or active ingredient Terpinen-4-ol
• They can sting, need to advise px to keep their eyes closed for 15-30s afterwards
• Use at night – when mites tend to pop out at base of lashes
• Most manufacturer recommend morning & night
• Can also advise a facial tea tree wash

Question 10

Describe other potential demodex management?

Answer 10

• Various other agents have been suggested but large-scale research trials are required
  o Manuka honey
  o Castor oil
  o Okra compounds
• Drugs currently used for dermatological conditions
  o Ivermectin
  o Metronadazole
• Produce licensed by FTA (Xdemvy)
  o Lotilaner ophthalmic solution (BD for 6 weeks)

Question 11

Describe level 2: lipiflow (DED)?

Answer 11

• In-practice tx offered by some clinics throughout UK
• Aim is to manually express lipid from MGs by simultaneously heating & massaging eyelids, takes 12mins
• Offered by one of multiples for £395 per eye with recommendation of repeat procedure every 12-18mths
• Cup onto eye like CL – heat inside eyelid, part on outside massages – so heat & massage

Question 12

Describe level 2: IPL (DED)?

Answer 12

• Intense pulsed light
• Previously been used to deliver pulses of light to help with skin pigmentation & acne
• Now being used for MGD
• One theory is that pulsed light liquefies contents of gland & optom expresses material to allow normal flow of meibum
• Available commercially in UK, usually repeated several times
• One independent (lol!) offering £120 per tx, plus £30 for expression, repeated 3 times
• Also been proposed as a potential management option for Demodex
• Recent studies show a reduction in mite count
• Works via a heat transfer
• Considerations in IPL:
  o Fitzpatrick skin type V or VI – high risk of permanent skin lightening
  o Could also cause lightening/darkening of skin
  o Pregnancy/breastfeeding/hx or active skin cancer/connective tissue disorder/ tanning bed/ metal plates or rod etc in face/ active herpes infection