- Diagnosis of Ocular Surface Disorders
Patients with compromised ocular surfaces have greater potential for discomfort or further ocular damage. Early recognition of the signs of infection and prompt diagnosis minimize the potential for severe or chronic complications. Evaluation of a patient exhibiting dry eye symptoms or blepharitis includes many of the elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and adnexa. (Refer to the Optometric Clinical Practice Guideline on Comprehensive Adult Eye and Vision Examination.) The evaluation for ocular surface disorders includes a carefully detailed patient history, an assessment of associated risk factors, and an examination of the anterior ocular structures and their functions.
- Patient History
Demographic data about the patient should be collected prior to taking the patient history. Included in the patient history are the chief complaint, ocular history, general health history (which may include a social history and an extended review of systems), and family ocular and medical history. In addition, environmental factors relating to climate, season, vocational setting, and avocational pursuits should be reviewed.
- Ocular Examination for Dry Eye
Observations, using external ocular examination techniques, both without magnification and with the biomicroscope, show characteristic early changes of the external eye. Evaluation for suspected ocular surface disorders may include, but is not limited to, the following:
- External view of the eye, noting lid structure, position, symmetry, and blink dynamics
- Biomicroscopic examination of the lid margins, meibomian gland orifices and their contents
- Biomicroscopic examination of the tear film, noting mucus, debris, interference patterns in the lipid layer, and tear meniscus height
- Biomicroscopic examination of the cornea and conjunctiva, both with and without sodium fluorescein and rose bengal or lissamine green staining.
Tear quantity tests are useful in confirming the diagnosis of aqueous deficient dry eye. The most frequently utilized procedures are:
- Schirmer tear test
- Fluorescein staining
- Evaluation of the tear prism
- Debris in the tear film
- Rose bengal staining
Other tests that may be used to evaluate tear quantity include:
- Schirmer II (irritation)
- Lissamine green staining
- Tear volume measurements
- Lacrimal equilibration time
- Cotton thread test
- Phenol red thread test
- Fluorophotometry; fluorescein dilution
- Temporary punctal occlusion
Several procedures are commonly used to evaluate tear film stability.
- Tear film breakup time (BUT)
- Tear-thinning time
- Lactoferrin concentration tests: LactoPlate® and LactoCard®
- Lysozyme radial diffusion assay: Quantiplate
Other tests that may be used to evaluate the quality of the preocular tear film (POTF) are:
- Tear osmolarity test
- Conjunctival scraping and biopsy
- Mucin assay test (tear ferning)
- Specular reflection of the tear surface
- Impression cytology
- Tear protein analysis
- Lipid layer interference patterns
- Enzyme-linked immunosorbent assay (ELISA) tear protein profile
- Ocular Examination for Blepharitis
A thorough external examination of the lids and other parts of the adnexa, including comparison of the eyes, helps determine the severity of the inflammation. Differentiating among the various presentations of blepharitis requires the use of the biomicroscope to contrast the appearance of the anterior and the posterior lid margins. Evaluation of the patient with blepharitis may include, but is not limited to, the following:
- External examination of the eye, including lid structure, skin texture, and eyelash appearance; and evaluation for clinical signs of acne rosacea (i.e., telangiectasia, pustules, rhinophyma)
- Biomicroscopic examination of the lid margins, the base of the lashes, and the meibomian gland orifices and their contents
- Examination of the tear film for lipid layer abnormalities
Each type of blepharitis has specific characteristics that help in making the diagnosis. These are described in detail in the original guideline document.
- Management of Ocular Surface Disorders
- Management of Dry Eye
- Basis for Treatment
Stepwise determination of the minimum intervention required to achieve results will help ensure a balance of patient compliance, long-term success, and cost-effectiveness. The management of dry eye is designed to reduce symptoms and inflammation and to re-establish a normal ocular surface. Efforts should be aimed at maintaining or restoring the preocular tear film and ridding the lids of potential sources of tear film destabilization. Whenever possible, environmental factors contributing to dry eye should be identified and either modified or eliminated. When associated medical conditions are identified, consultation with or referral to the patient's primary care physician or other health care provider may be indicated.
- Available Treatment Options
Attempts to relieve dry eye symptoms and re-establish a normal ocular surface have produced a myriad of possible remedies. Traditional approaches include both tear supplementation and tear conservation measures. Several alternatives have been used with varying degrees of clinical success:
- Ocular hygiene
- Topical treatment with tear supplements, ointments, and soluble polymeric inserts
- Punctal occlusion
Alternative methods for relieving symptoms specific to ocular surface disorders include:
- Hydrophilic bandage lenses and collagen corneal shields
- Moisture chamber goggles
- Tarsorrhaphy
- Estrogen replacement
- Salivary gland transplant
- Limbal grafts
- Management of Blepharitis
- Basis for Treatment
Acute sequelae to blepharitis are usually the direct result of infection of the lipid-producing glands that open to the lid margin. Their clinical presentation includes internal and external hordeola. The treatment is relatively straightforward. Though essential, lid hygiene alone may not resolve the problem. Depending upon the clinical findings, an appropriate anti-infective drug can be administered topically, systemically, or in combination. On the other hand, chronic blepharitis is a disease for which there is no complete cure. Aggressive therapy should initially include a minimum of 6 weeks of lid hygiene and appropriate anti-infective medications to gain control of the condition, followed by continuing treatment to maintain control of chronic blepharitis.
- Available Treatment Options
Because each category of blepharitis is actually a separate condition, each is addressed individually in the original guideline document. Treatment approaches for the following forms of blepharitis are discussed in greater detail in the guideline document:
- Staphylococcal blepharitis
- Seborrheic blepharitis
- Seborrheic/staphylococcal blepharitis
- Meibomian seborrheic blepharitis
- Seborrheic blepharitis with secondary meibomianitis
- Meibomian keratoconjunctivitis
- Angular blepharitis
- Demodicosis
- Patient Education
When there is no previously known local or systemic cause for the ocular findings, the patient should be educated about other conditions possibly associated with the ocular surface disorder and assisted in obtaining further diagnostic evaluations.
When topical treatment for dry eye is prescribed, the patient should be given the rationale for treatment, along with the specific dosages, frequency, and duration. The patient should be made aware of the expected results and given instructions to follow in case of adverse effects. A follow-up examination of the patient should be scheduled to assess treatment effectiveness.
The treatment of blepharitis requires close, ongoing cooperation between the patient and the practitioner. Thorough discussion of the causes, the rationale for treatment, and the expected results is essential in the management of this condition. Most patients with blepharitis have a significant improvement in their symptoms when the appropriate hygiene, topical, and/or systemic treatments are instituted. Because there is no cure for the chronic forms of blepharitis, patients must actively participate in steps to control the inflammatory process. Thorough explanation of both the chronicity of the disease and the rationale for the therapy helps encourage patient compliance. Specific instructions and realistic expectations for the abatement of symptoms should be reinforced by scheduled follow-up.
- Prognosis and Follow-Up
Follow-up visits for treatment of blepharitis may be as frequent as every few days at the outset, tapering off to once or twice a year after stabilization of the condition. The frequency and composition of evaluation and management visits for dry eye are summarized in the table below.
Table 1. Frequency and Composition of Evaluation and Management Visits for Dry Eye
Type of Disorder
Mild Keratoconjunctivitis sicca (KCS)
Frequency of Examination: Annual or as necessary
(p.r.n.)
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein, rose
bengal, breakup time (BUT) up to p.r.n.
Management: Preserved or unpreserved tear
supplements daily (q.d.)
Moderate KCS
Frequency of Examination: Every 6-12 months or
p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein, rose
bengal, BUT, Schirmer test
Management: Unpreserved tear supplements 4-5
times a day up to p.r.n.
Severe KCS
Frequency of Examination: Every 3-6 months or
p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein, rose
bengal, BUT, Schirmer test
Management: Unpreserved tear supplements p.r.n.;
ointment at bedtime (h.s.), punctal occlusion
Severe KCS associated with systemic disease
Frequency of Examination: Every 1-3 months or
p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein, rose
bengal, BUT, Schirmer test
Management: Unpreserved tear supplements p.r.n.;
ointment at bedtime (h.s.), punctal occlusion; refer to primary
physician
Table 2. Frequency and Composition of Evaluation and Management Visits for Blepharitis
Type of Disorder
Seborrheic blepharitis
Frequency of Examination: Weekly until stable,
then p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene three times per
day (t.i.d.) until improved, then daily
Staphylococcal blepharitis
Frequency of Examination: Twice a week until
cleared, then p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Antibiotic or antibiotic/steroid ointment (ung.) h.s. to t.i.d.; tear supplements p.r.n.; steroid drops or ung. if infiltrates; lid hygiene t.i.d. until improved, then q.d.
Seborrheic/staphylococcal blepharitis
Frequency of Examination: Twice a week until
controlled; then every 6 months or p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Antibiotic or antibiotic/steroid ung. h.s. to t.i.d., then lid hygiene q.d. to t.i.d. for control
Meibomian seborrheic blepharitis
Frequency of Examination: Twice a week until stable, then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene up to t.i.d.;
scalp shampoo q.d.; meibomian express q.d.; antibiotic or antibiotic/steroid
ung. h.s. to t.i.d.
Seborrheic blepharitis with secondary meibomianitis
Frequency of Examination: Twice a week until
stable (up to 8 weeks), then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene up to t.i.d.; antibiotic or antibiotic/steroid ung. h.s. to t.i.d.; oral tetracycline or doxycycline (taper)
Meibomian keratoconjunctivitis
Frequency of Examination: Twice a week until stable (up to 2 weeks), then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene; antibiotic or
antibiotic/steroid ung. h.s. to t.i.d.; oral tetracycline or doxycycline (taper)
