38 EWAP SEPTEMBER 2023 CORNEA exam, Dr. Perry moves on to testing, noting that he uses the osmolarity test, MMP-9 testing, the Schirmer 1 test (which can show if the patient has significant aqueous deficiency), lissamine green staining (to see if there are changes on the ocular surface), and meibography. “I will frequently express the lower meibomian glands to look at the meibum, and this is usually helpful and somewhat therapeutic as it often helps increase the flow of the meibum again,” he said. Treatments Dr. Perry noted a study that he was a part of where patients with symptomatic blepharitis were treated with warm saltwater soaks and preservative-free tears. 6 This was done for 6 weeks, and patients were reevaluated. Dr. Perry said 88% of patients got better. “It was heartening to realize that patients could get better with non-medicinal therapy,” he said. This saltwater method helps with lid hygiene, he said. The heat helps melt fats in the eyelid, the saline solution is calming for the eye, and the action of the cotton ball on and off cleans the eyelid and debrides some allergens that might be stuck to the eyelid skin. It’s helpful to have a non- medicinal option, he said, because corticosteroids can cause thinning of the eyelid skin and can lead to the complications of glaucoma and cataract formation. For those patients who need additional treatment, Dr. Perry said there are options like Prokera (BioTissue) and several cyclosporine medications. Additionally, Dr. Perry said it’s important to consider nutritional therapy. He recommends patients take fish oil supplements. Most patients with severe meibomian gland dysfunction have associated acne rosacea and don’t eat any fish, he said. Speaking specifically about staphylococcal blepharitis, Dr. de Luise said it is often chronic and recurrent; patient education is essential as the condition is rarely curable. Therapeutic strategies include warm compresses and saltwater lid scrubs. Do not use shampoos or soaps in lid scrubs as blepharitis is a condition in which the eyelid surface is already saponified, and the shampoos can worsen the condition. Hypochlorous acid cleansers can be helpful. In more severe cases in which the patient is not a steroid responder, the short-term use of an antibiotic-steroid ointment or drop can be effective. 4,5 In terms of new therapies in development, Dr. Perry said that Novaliq is working on a cyclosporine product with a new type of excipient (fluorinated alkanes) that will also treat meibomian dysfunction. Dr. Perry is studying some new drugs that are similar to Oxervate (cenegermin-bkbj, Dompé) that have healing qualities on the ocular surface. “We’re looking at two other agents, one with germ cell properties and one with a different growth factor compound,” he said. Are some types of blepharitis harder to treat? What about Demodex? Acarid mites in the genus Demodex can be associated with anterior blepharitis or posterior blepharitis, meibomian gland dysfunction, oculocutaneous rosacea, and keratitis. Whether Demodex mites are causative or just correlative is debated, Dr. de Luise said. Demodex blepharitis should be suspected in cases of symptomatic patients who are non-responsive to treatment of other anterior segment conditions, he added. Demodex infestation is termed demodicosis and is common. It has been estimated that almost half of adults with some type of blepharitis harbor Demodex mites, Dr. de Luise said. Symptoms and signs of demodicosis include eyelid irritation, blurry vision, ocular discomfort, itching, burning, foreign body sensation, collarettes around eyelash bases, crusting, or matting of eyelashes and tearing. Misdiagnosis can occur because of the poor correlation between Demodex infestation and symptoms. Demodex mites are found in both symptomatic and asymptomatic individuals. The ocular symptom that correlates most directly with Demodex is lid irritation. Demodex mites can cause ocular inflammation by direct mechanisms as well as indirectly. 1 The overarching goal in the treatment of Demodex infestation is to reduce eyelid margin mite populations, which in turn reduces ocular surface inflammation. There is no current FDA-approved agent for demodicosis. Demodicosis does not respond to hot compresses or antibiotic - steroid ointment. There are many topical treatment strategies for demodicosis, none of which are curative, Dr. de Luise said. One of the more efficacious strategies is the use of topical tea tree oil. Cliradex is a lid wipe that contains terpinen-4-ol, which is the most active ingredient in tea tree oil. Another option for demodicosis is the use of OCuSOFT Lid Scrub Plus or TheraTears scrubs. Several companies are analyzing pipeline medications for demodicosis. Two companies in this domain are Tarsus Pharmaceuticals, which is looking at an ophthalmic formulation of the acaricide lotilaner, and Azura Ophthalmics, which is investigating a selenium sulfide component, AZR - MD - 001. 2 References 1. Shah PP, et al. Update on the management and treatment of Demodex blepharitis. Cornea. 2022;41:934 – 939. 2. Heczko J, et al. Evaluation of a novel treatment, selenium disulfide, in killing Demodex folliculorum in vitro. Can J Ophthalmol. 2022. Online ahead of print.
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