Blepharitis prevalence and management studied in recent surveys

Key Points

Dr. McDonald is the head of ICare in America, a faculty of key opinion leaders in the area of eyelid and ocular surface disease convened to review the results of two surveys recently conducted to gather information from patients and eye care specialists about the prevalence and management of blepharitis in America.

"Even though blepharitis is one of the most common conditions seen by eye care practitioners, there has been a shocking paucity of data in the peer-reviewed literature about its epidemiology and management," said Dr. McDonald, clinical professor of ophthalmology, New York University School of Medicine, New York, and in private practice, Ophthalmic Consultants of Long Island, Lynbrook, NY.

"Most of the clinical features probed in the survey represent findings that are almost pathognomonic for blepharitis, including eyelid itching or burning, heavy or puffy eyelids, and the presence upon waking of lash crusting or flakes, lids stuck together, watery eyes, and redness," said Dr. McDonald.

The survey results showed that about 80% of patients reported experiencing at least one of the blepharitis-related symptoms within the past 12 months. Nearly two-thirds had two or more symptoms during the past year, and one-third experienced at least one symptom half the time. A history of styes was also relatively common (18%) and eyelash thinning, a late complication of untreated blepharitis, was reported by 9% of survey participants. Overall, symptom prevalence was similar between genders.

"Extrapolating the survey prevalence data to the adult U.S. population suggests that blepharitis may affect more than 180 million people in this country. This is an important issue because the clinical features of blepharitis not only cause distress and discomfort, but untreated blepharitis is a risk for infections after ocular surgery. It can also have an important impact on one's personal life and in the workplace considering that watery and red eyes may be mistaken as signs of excessive crying or alcohol consumption," Dr. McDonald said.

While 15% of survey participants had at least one of the three most common classic symptoms of blepharitis (eyelid crusting or flakes upon waking, eyelids stuck together upon waking, eyes or eyelids red upon waking) more than half the time in the past year, blepharitis had been diagnosed in only 1% of the survey participants while dry eye had been diagnosed in 11%.

"Forty percent of respondents who said they had been diagnosed [as having] blepharitis also said they had concomitant dry eye, and respondents with symptoms consistent with blepharitis also frequently reported difficulty wearing contact lenses.

"These findings are not surprising, recognizing that posterior blepharitis is an underlying etiology of evaporative dry eye disease and for that reason can interfere with contact lens wear comfort," Dr. McDonald said.

Eye care professionals

A second survey queried ophthalmologists (n = 120) and optometrists (n = 84) to gain their perspectives on blepharitis prevalence, comorbidities, and management. Its key findings showed that the majority of patients with an ultimate diagnosis of blepharitis presented because of blepharitis or dry eye symptoms. In addition, the data highlighted an age-related increase in prevalence, with men over 65 years of age being affected most (32.5%).

Both ophthalmologists and optometrists recognized that dry eye disease is a common comorbidity with posterior blepharitis, and that posterior blepharitis is a common cause of evaporative eye disease and contact lens intolerance, although about one-fourth of ophthalmologists failed to appreciate the latter association.

"These data may reflect a difference in scope of practice with ophthalmologists being particularly focused on identifying and managing blepharitis in presurgical candidates," Dr. McDonald said.

This concept is supported by responses to questions about treatment goals that showed that among ophthalmologists, decreasing bacterial load was a main goal for managing anterior blepharitis, while optometrists placed greater emphasis on reducing symptoms. However, the responses also showed that both groups recognize lid margin inflammation as a key component of anterior and posterior blepharitis, place importance on resolving inflammation as a treatment goal, and consider anti-inflammatory properties as a key attribute for a blepharitis treatment option, Dr. McDonald observed.

Nearly 70% of survey participants indicated they recommend treatment for blepharitis and more than half (53%) said they write a prescription for patients with a diagnosis of blepharitis.

"It is important to note that not all patients issued a prescription will have it filled. In fact, we are now seeing a significant increase in the number of patients who are failing to fill prescriptions for ocular infections and glaucoma because they can not afford their medication," Dr. McDonald said.

Responses to questions about the most frequently prescribed medications showed topical azithromycin and oral doxycycline were chosen most often.

"With emerging evidence showing topical azithromycin is rapidly and highly effective for treating anterior and posterior blepharitis, and more effective than previous topical options, we are seeing greater patient acceptance of blepharitis treatment regimens. There was always a significant pushback from the use of previous conventional treatments at night, such as erythromycin or bacitracin ointment. This is not surprising considering that these agents have a number of limitations, including marginal penetration into the eyelid margins, the potential to cause vision-disturbing blur, which can lead to accidents, especially with older patients, and difficulties with safe and proper application," Dr. McDonald said.

Clinical trial data

In 2008, Jodi Luchs, MD, published the results of his study demonstrating that a 2-week course of azithromycin ophthalmic solution 1% (AzaSite, Inspire Pharmaceuticals) combined with warm compresses was significantly more effective than warm compresses alone in treating the signs and symptoms of posterior blepharitis. Results have recently been analyzed from a pilot, open-label, two-center study that enrolled 26 patients with moderate to severe chronic blepharitis with presence of anterior and meibomian gland disease diagnosed. In this study, all patients used azithromycin ophthalmic solution for 4 weeks, beginning with twice daily administration for 2 days and then continuing with just daily use. However, lid scrubs and warm compresses were not allowed for 2 weeks prior to initiation of azithromycin and for the entire course of treatment.

Changes in a number of blepharitis-related clinical signs and symptoms were evaluated as the primary outcome measure, including investigator-rated eyelid margin hyperemia and subject-rated foreign body sensation. For both endpoints, there was a statistically significant improvement from baseline to end of treatment that was maintained at two subsequent follow-up visits approximately 2 and 4 weeks post-treatment (p < 0.001 for all comparisons versus baseline scores).

Mean eyelid margin hyperemia, scored using a scale of 0 (normal) to 3 (severe), decreased from 2.0 at baseline to 1.3 at the end of treatment and was 1.2 at the final study visit. Foreign body sensation was rated on a 5-point scale of 0 (none) to 4 (severe). The mean score was 2.2 at baseline, 0.7 at day 29, and remained <1.0 at the two post-treatment follow-up visits.

"Topical azithromycin is a broad-spectrum antimicrobial with very significant anti-inflammatory effects. These impressive improvements were achieved without lid hygiene, which is part of any blepharitis treatment regimen," observed Dr. McDonald.

"In another study from Dr Luchs, when topical azithromycin was combined with lid hygiene, there was an even more dramatic and rapid reduction in the signs and symptoms of blepharitis," Dr. McDonald concluded.