TERM 1 Lid margin disease

Question 1

What is the anatomy of the eyelid margin?

Answer 1

Eyelash zone: 2-3 rows of eye lashes
Grey line: represents the location of Riolans muscle and divides the lid into anterior and posterior lamellae
Meibomian gland duct openings
Mucocutaneous junction

Question 2

What is the anatomy of the meibomian glands?

Answer 2

-Large sebaceous glands located in the tarsal plates of the eyelids
-Longer and more numerous in the upper lid
-Each gland consists of multiple secretory acini which open onto a central duct that discharges its contents onto the lid margin

Question 3

What is the purpose of meibomian glands?

Answer 3

-synthesise and secrete a complex mixture of lipids that spread onto the tear film to reduce tear evaporation and contribute to tear stability

-The lipid mixture has a melting range in the region of 19.5°C to 40°C, which ensures lipid mixture fluidity

• meibum is used to describe this secretion

Question 4

What are the features of lid margin disease?
What are the associations?

Answer 4

chronic
relapses and remissions
bilateral

• linked with dry eye disease
• linked to the development of post-operative infection (endophthalmitis) following ophthalmic surgery

Question 5

What are the classifications of lid margin disease?

Answer 5

Anterior lid margin disease: affecting the anterior lid margin and eyelashes

Posterior lid margin disease: affecting structures posterior to the grey line, including Meibomian gland dysfunction (MGD)

Mixed anterior and posterior disease

Question 6

What are the cutaneous associations of lid margin disease?

Answer 6

Acne rosacea
-common in fair-skinned people and women
-Occurs in the second half of life Associated with facial flushing and telangiectasia
- papules and pustules affecting the forehead, cheeks and nose
-Ocular involvement in 50% of cases

Seborrheic dermatitis
-Chronic, relapsing inflammatory skin condition, occurring in skin areas rich in sebaceous glands such as the scalp, face, chest
-Characterized by scaling and poorly defined erythematous patches

Question 7

What are the symptoms of lid margin disease?

Answer 7

-ocular surface discomfort: itching, burning, irritation, dryness, watering/tearing
- vision fluctuation
- puffiness or redness of the eyelids
- crusting on the lashes
- eyelids being stuck shut in the morning
-Symptoms vary in frequency and severity
-May cause contact lens intolerance
-May be linked with particular activities e.g. computer use or driving

Question 8

What does anterior lid margin disease include?

What is the cause?

What are the signs?

Answer 8

affects the lid margin in the region of eyelashes

-overgrowth of gram + bacteria (staph)
-mite infestation (demodex folliculorum)

• scaling or ‘collarettes’ at the base of the eyelash
  -Associated with loss or misdirection of lashes
  -Redness of the lid margins and conjunctival hyperemia
  -May show corneal involvement e.g. superficial punctate keratitis

Question 9

What is posterior lid margin disease associated with?

What is it characterised by?

What are the associations?

Answer 9

MGD

-terminal duct obstruction and qualitative/quantitative change

evaporative dry eye
contact lens intolerance
demodex brevis infestation

Question 10

What are the signs of MGD?

Answer 10

altered quantity or quality of secretion
Plugging of Meibomian gland openings
Lid margin hyperemia
Foaming of tears
Notching of posterior lid margin
Increased lid margin vascularity (telangiectasia)

Question 11

What is the sequence of tests to do in someone presenting with symptoms of ocular surface disease?

Answer 11

Dry eye investigation (e.g. tear meniscus height, tear break up time, Schirmer test, corneal and conjunctival staining with fluorescein and (lissamine green))

Observation of morphologic features of the lid margins

Expression: quantification of meibum expressibility/quality

Question 12

How can you grade meibomian gland excretions?

Answer 12

Meibum quality is assessed in 8 glands of the central third of the lid (0= clear, 1=cloudy, 2=cloudy with debris (granular), 3= thick (like toothpaste). Grade 0-3 for each of 8 glands (range 0-24)

Expressivity of meibum from 5 glands (1= 3-4 glands expressive, 2= 1-2 glands expressive, 3= no glands expressive)

Question 13

What is the management of lid margin disease?

Answer 13

Lid hygiene
Warm compresses

Pharmacotherapy:
Lubricants
Topical antibiotics
Systemic antibiotics

Question 14

`Why do we recommend warm compresses?
How should you do warm compresses?

Answer 14

Warm compresses to loosen collarettes and crusts in anterior blepharitis and to melt meibum in posterior blepharitis

two to four times daily for 5 to 10 minute intervals
Warm flannel or commercially available products
May be associated with eyelid massage

Question 15

How can you include massage in lid margin disease management?

Answer 15

-massage the eyelids use the index finger and sweep the pad of the finger from the inner to outer canthus (stabilise the lid by placing the index finger of the other hand on the outer canthus)
Repeat this with the lower lid, placing the pad of the finger just below the lashes at the inner canthus and sweeping outwards towards the temple
Repeat 5 to 10 times over about 30 seconds immediately following the warming

Question 16

How can you carry out lid hygeine?

Answer 16

diluted baby shampoo (1:10) solution with a swab or cotton bud, patient cleans lid margins (but not beyond the muco-cutaneous junction).

Carry out twice daily at first; reduce to once daily as condition improves. Use firm pressure with swab or cotton bud so as to express glands

commercial products e.g. dedicated lid cleaning solutions or impregnated wipes

avoid eyeliner and mascara

Question 17

What pharmacological options are there for lid margin disease?

Answer 17

Ocular lubricants or liposomal spray to manage associated dry eye

Topical antibiotics to reduce bacterial load on the lid margins
e.g. fusidic acid or chloramphenicol

Systemic tetracyclines used in the treatment of rosacea and some evidence for their effectiveness in MGD e.g. doxycycline, minocycline 50-100mg 1-2 times per day, thought to work by supressing bacterial lipases that alter Meibomian secretions

Question 18

How can diet be used to manage lid margin disease?

Answer 18

some benefits of omega-3 fatty acid supplements

Question 19

How can you manage demodex?

Answer 19

dose-dependently killed by weekly lid scrub with 50% tea tree oil
should be undertaken only by experienced practitioners as such preparations are toxic to the ocular surface