Steroids in the Treatment of Blepharitis
Steroids in the Treatment of Blepharitis
David A. Goldman, MD
While steroids have traditionally been reserved for inflammation resulting from ocular surgery or diseases such as uveitis, these drugs can also play a role in the treatment of some chronic conditions like blepharitis. Although the inflammation seen in blepharitis is typically mild, a steroid can be used to break the cycle of inflammation and help to reestablish a healthy ocular surface environment as a prelude to long-term management with other agents. When selecting a treatment for blepharitis, I consider steroids and other antiinflammatory medications, as well as antibiotics and non-medical therapies such as warm compresses.
Classically, blepharitis has been divided into two forms: anterior and posterior. Anterior blepharitis is characterized by scurf on the eyelid margins and dandruff and collarettes around the base of the eyelashes. Posterior blepharitis is characterized by inspissation of the meibomian glands, crusting on the eyelid margin, telangiectasia of the posterior lid margin, and a frothy tear film. While I consider these two presentations to be the result of two distinct disease entities, the clinical reality is that they frequently co-occur. When they occur separately, I believe posterior blepharitis is somewhat more common than anterior blepharitis.
Need for Treatment
For most patients who present with symptoms of blepharitis, I select a treatment regimen based on clinical signs, the severity and duration of symptoms, and the patient’s history. For these patients, my goal is almost always to alleviate symptoms and reestablish a healthy ocular surface. Which treatments I select to achieve this goal depend on the specific clinical presentation.
I rarely treat an asymptomatic patient, even if there are signs of blepharitis, unless the patient has been scheduled for ocular surgery. In these cases, it is particularly important to educate the patient about his or her condition preoperatively, because the surgery will almost surely exacerbate the condition, making the patient symptomatic. In that situation, I don’t want the preexisting blepharitis attributed to the surgery (or to the surgeon). In most cases, preexisting blepharitis should also be treated in order to minimize the risk of surgical complications and to optimize surgical outcomes. Especially with premium intraocular lenses (IOLs), even small amounts of ocular surface inflammation and/or dryness can affect the visual outcome.
Benefit of Topical Steroids
Although blepharitis is a chronic condition, quelling acute inflammation is often a necessary first step in treatment, and I believe a strong steroid can be ideal for achieving this goal. By reducing inflammation quickly and effectively, a strong steroid not only interrupts the inflammatory cycle but also provides immediate relief for patients, which is particularly important in a referral setting such as my clinic—I frequently see blepharitis patients who have been treated by multiple doctors with multiple therapies, none of which have been successful. In that setting, I want a drug that will provide rapid amelioration of symptoms so that the patient will have confidence in my ability to provide effective therapy.
To gain this rapid resolution of inflammatory symptoms, I often use difluprednate (Durezol™; Alcon) as my initial treatment. While such a potent steroid may seem to be more than is needed for blepharitis, I believe it can be quite beneficial, since its potency ensures a prompt clinical response and allows me to limit the duration of treatment. Once the acute inflammation has been resolved, the steroid can be discontinued and other therapies can be used for long-term maintenance.
With all strong steroids, there is a risk of intraocular pressure (IOP) rise, so care must be taken when deciding to use these drugs. A strong steroid is almost always contraindicated in glaucoma suspects or patients on glaucoma medications. In most other patients, a steroid can usually be used safely so long as IOP is monitored carefully.
Cataract formation is also a risk with steroid use, especially long-term use. This is not a concern if I am treating patients prior to cataract surgery, but if a patient is phakic and has clear crystalline lenses, then those lenses should be monitored and long-term steroid use avoided.
Other Medical Therapies
While steroids can play a role in the treatment of blepharitis, several other medical therapies are also available and can be used instead of or in conjunction with steroids.
In a study by Luchs, topical azithromycin (AzaSite®; Inspire) was found to improve the severity of symptoms in blepharitis patients1 and other topical antibiotics are also routinely used in these patients. In many cases, both an antibiotic and a steroid are indicated, in which case combination agents are useful, such as TobraDex® (tobramycin and dexamethasone ophthalmic suspension; Alcon), Zylet® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension; Bausch & Lomb), or Maxitrol® (dexamethasone and polymyxin B sulphate and neomycin sulphate; Alcon).
While topical antibiotics may not have the immediate effect of steroids, the safety profile of these drugs makes them better for long-term control of blepharitis. Antibiotics can still have side effects, however, so clinicians should take care when determining which patients should receive antibiotics, steroids, or both. For example, tobramycin can affect the cornea and cause some epithelial breakdown, which may make it unsuitable for certain patients. Another caveat is that extensive use of topical antibiotics could increase the risk of bacterial resistance, so preoperative use of these drugs should be limited.
In addition to topical antibiotics, oral tetracyclines offer a good option for some patients. Particularly for individuals with posterior blepharitis, lid telangiectasia, and/or ocular rosacea, drugs such as doxycycline and minocycline are excellent medications, and patients can be maintained on these drugs chronically if needed.
Finally, fish oil and other foods and supplements rich in omega-3 fatty acids may have an antiinflammatory effect and are thought to improve the quality of the tear film, so I often recommend such supplements to patients with blepharitis. While supplements do not provide an immediate benefit, they can be used as part of a long-term maintenance regimen.
While antiinflammatory drugs and antibiotics are increasingly becoming key components of blepharitis treatment, non-medical therapies remain valuable. For example, warm compresses can help to improve the viscosity of tear secretions in patients with posterior blepharitis. I recommend warm compresses for all patients with posterior blepharitis.
Similarly, eyelid scrubs can help to remove some of the dandruff and lid scurf that occurs in anterior blepharitis. However, since eyelid scrubs can potentially disturb the ocular surface, I limit their use to patients with obvious signs of anterior blepharitis.
Pearls for Treatment
As with any condition, proper diagnosis of blepharitis is essential in order to achieve good outcomes. Clinicians should thus pay careful attention to the patient history and rule out other conditions that can masquerade as blepharitis, such as aqueous tear deficiency or ocular allergy.
Patient education is also essential. Patients need to understand that blepharitis is a chronic disease that may require long-term management, even after the acute signs and symptoms have resolved. Patients have reason to be optimistic about finding relief, as multiple treatment options are available; however, patience is also required, since it may take several tries to find the best treatment regimen.
THE BOTTOM LINE
A complex condition with both infectious and inflammatory components, blepharitis often requires a multifaceted approach to treatment. In my experience, using a strong steroid as part of this regimen can help to quickly quell ocular surface inflammation and speed resolution of symptoms. For this reason, I often treat patients with difluprednate initially, and then switch to antibiotics and/or other antiinflammatory medications for long-term management.
David A. Goldman, MD, is an assistant professor of clinical ophthalmology at the University of Miami’s Bascom Palmer Eye Institute in Miami, FL. He is a consultant to Alcon, Allergan, and Aton Pharma; and he receives grant support from the ASCRS Foundation. Refractive Eyecare managing editor Kay Downer assisted in the preparation of this manuscript.