Last time on Eye to the Future we discussed Posterior Blepharitis, this time we will cover the second type:  Anterior Blepharitis.

Anterior Blepharitis occurs at the front outside edge of the eyelid at the base of the eye lashes and/or further up onto the sensitive eye lid skin.  There are three main types of anterior blepharitis.

• Seborrheic Blepharitis (picture right) – This chronic condition occurs on the sensitive eye lid skin at the level of and continuing up or down the lid from the lash line; although it is more common on the upper eyelid.  This condition is a subtype of dermatitis that causes malfunction of sebaceous glands (oil producing glands) on the eye lid skin and often occurs in conjunction with dermatitis elsewhere on the head and face.  This condition occurs secondary to hypersensitivity to the presence of bacteria or fungus, genetics, or environmental or health factors. Regardless of the underlying cause, this condition results in flaking, cracking, crusting, or dandruff on the eyelid skin along with crusting of the skin or lashes and erythematosus (redness and inflammation) of the lid.  The main treatment for this condition is prescription antibiotic and/or steroid creams.

• Bacterial Blepharitis – This type of blepharitis occurs from a either an acute or a chronic bacterial infection of eyelid margin at the base of the eyelashes.  Typically this infection comes from gram-positive Staphylococcal or simply “Staph” bacterial with the most common culprit in this family being Staph Aureus (electron micrograph image right).  These Staph bacterial are extremely common on the human skin and in the eyes, but inflammation or infection comes from over population or hyper sensitivity to these bacterium.  In acute cases, over population of bacterial causes a sudden, active, and contagious infection of the eyelids with redness, moderate to severe crusting and matting.  This infection can also cause a concurrent infection on the white of the eye called conjunctivitis (“pink eye”) and in severe cases a keratitis which is an infection on the cornea.  Although acute bacterial blepharitis is common, since this bacterial is so commonly found on the skin surface it is more common to see a chronic long term hypersensitivity to the offending bacterium.  Chronic bacterial blepharitis causes less overt symptoms but far worse, long term, and irreversible complications including crusting, thickening, ulceration, scarring of the eyelids, and permanent loss of lashes (seen at left).

• Demodex Blepharitis – I promised you parasites!  Like Staphylococcal bacteria, Demodex (pictured at right) are also a ubiquitous and largely benign resident of the human skin.  Demodex are a parasitic mite that spends its life living inside the hair follicles of ALL mammals.   You are probably familiar with mange in dogs?  Yep, that’s demodex (infected follicle at right).  The prevalence of eyelash demodex  in humans increases with age – from 85% prevalence by age 60 to nearly 100% of humans by age 70, but it is commonly found in patients of all age ranges.  Luckily for us, the vast majority of the time, this parasitic relationship occurs without any problems or symptoms.
  Problems with this type of blepharitis occur if there is an over population of these mites or if an individual is overly sensitive to the presence of these mites.  The hallmark of Demodex infestation is clear, glistening, cylindrical dandruff at the base of the eyelashes as seen under an eye doctor’s microscope (below).  The waste byproducts and bacteria associated with these mites are what cause the inflammation of the eyelids and leads to discomfort and dryness on the eye.
  There is also a known link between Rosacea and increased overpopulation of Demodex.  The good news is that the life span of a Demodex mite is short (about 20 days); however the bad news is that these mites will mate and reproduce if the infection is not controlled.  Treatment for a mite problem is to cull their ranks with readily available eyelid cleaners containing tea tree oil which are very effective at lowing the overall population.  It is very common, however, for the symptoms to return as the mites multiply over time.  Therefore, a daily eyelid cleaning
  regimen is very important to keep the mites at bay in the long term.

Thank you for joining us on this trip through the ins and outs of Blepharitis.  We hope we have shed some light on a common condition that can result in some very uncomfortable eyes.  Next week on Eye to the Future, we will take a look at a far more familiar (but not well understood) condition:  “Pink Eye”.

As discussed in our previous post.  Blepharitis has two types:  Anterior Blepharitis and Posterior Blepharitis.

Today we will be discussing the posterior form.

Posterior Blepharitis

This condition is also known as Meibomian Gland Dysfunction or simply MGD (no, not the frosty adult beverage).  This form of lid inflammation occurs at the inner edge of the eyelid next to the eyeball where the meibomian (or oil producing) glands are located.  As previously mentioned, these oil glands produce  a very important oil that coats over the watery layer of the tears with every blink.  Without proper amounts or quality of this oil the tear film becomes unstable and evaporates too quickly to keep the eye properly wetted.  As a result, Posterior Blepharitis is the leading underlying cause of evaporative Dry Eye Syndrome (DES).   Inflammation on this part of the eyelid results in these important oil glands clogging and become “capped” or “plugged up” as is shown above.  As these oil glands get clogged, the clear oil they typically produce turns to very thick almost cheesy oil (shown above) along with foamy or frothy tears (right).  In addition to problems with the oily layer, the natural bacterial in our tears also tends to get trapped in the clogged glands and can cause an infection of that gland; this is how stys are formed.

As this chronic inflammatory condition continues over months to years, the lids themselves continue to become more thickened and red, along with prominent engorged blood vessels and eventually the oil glands become dysfunctional all together which results in permanent scarring of the lids (photo below).  Patients with Posterior Blepharitis or MGD are generally older with a long history of ocular symptoms and dry eyes.  Another important note is that this condition is HIGHLY associated with Rosacea since the oil glands on the face where Rosacea occurs are very similar to the oil glands on the eyelids.

Clearly, if left unchecked, Posterior Blepharitis can cause substantial damage to the lids and the ocular surface over time.  How do we combat this process?  The answer here isn’t quite so simple.  This is a chronic condition and therefore, there isn’t a single treatment that works best for all patients nor is there a definite “cure”.  Depending on severity, there are a few treatments that are useful in most cases.  This three prong approach includes artificial tears in conjunction with proper eye lid hygiene maintenance and Omega 3 fatty acids (fish oils).  For the artificial tears, it is important to improve the oily layer, therefore we recommended an emollient or “oil rich” tear like Systane Balance or Soothe XP.  We have all been told since childhood to keep soap away from our eyes (and for good reason!  Ouch!), however this fact in combination with the bony orbit preventing access, make the lids the only place on the human body that never gets cleaned.  For our Blepharitis patients, we strongly recommend warm compresses to help loosen the clogged oil as well as routine eyelid cleaning with a dedicated (eye friendly!) cleaner like Ocusoft or Sterlid products.  Omega 3 fish oils are also a natural anti-inflammatory product which will also help the lids to produce better oil, and have the added benefit of being great for heart health.  As is often the case with this condition, if symptoms are more pronounced or if there is a risk of lid scarring or permanent damage, it is often necessary to go further with treatment including prescription eye drops or even oral antibiotics for several months to quell the inflammation and improve the functionality of these glands.

It’s important to remember that there is no “cure” for Posterior Blepharitis.  Sufferers from this condition need routine monitoring and sometimes aggressive treatment to maintain a comfortable and safe eye.

Stay tuned on Eye to the Future for the final installment: Anterior Blepharitis, next week.

What if we told you that there is a condition we see in around 40% of patients but was something that you’ve probably never heard about before?  How about if we mentioned that it is the leading cause of evaporative Dry Eye and a main cause of conjunctivitis (“pink eye”)?  Maybe we could peak your interest by saying Blepharitis is more common than Glaucoma, Macular Degeneration, and Retinal Detachments… combined!

Now that you’ve met the contributors to Eye to the Future, let’s kick off this educational blog by turning our eye to this largely unknown, nearly ubiquitous, and often overlooked and under treated condition with an in-depth look at Blepharitis.

What is Blepharitis?

Blepharitis (pronounced “blef-ah-RYE-tis”) is a non-specific term for inflammation of the eye lids and is incredibly common; affecting more than 80 million Americans.  The inflammation and irritation of the eyelids can occur secondary to several different sources which we will discuss in some detail, but regardless of the cause, the inflammation of those lids vastly affects the quality of the tears and often results in redness, ocular discomfort, Dry Eye Syndrome (DES), acute conjunctivitis (“pink eye”), and an overall poor cosmetic appearance of the eye.  The reason for all this is that the eyelids do far more than just blink to protect the eye.  With each and every blink, around 40 meibomian glands (or oil producing glands) on each of the four eye lids produce and excrete an oily substance.  This secretion acts as an “oil slick” that covers over the watery layer of the tears and decreases the rate at which the tears evaporate into the air.  The inflammation and irritation to these eyelids results in the improper function of these oil glands.  Compounding matters, we have all been told since childhood to “never get soap in our eyes” which makes the eyelids the only part of the human body that never gets cleaned.  This results in inflammatory compounds, oils, and overall crusting building up resulting in further inflammation the surface of the eye and more symptoms.  This vicious cycle leads to eyes in bad need of some TLC…

Types of Blepharitis

There are two main classifications of Blepharitis- Anterior and Posterior Blepharitis – and these terms are simply based on the location of where the lid inflammation is occurring.  Anterior Blepharitis occurs at the front outside edge of the eyelid at the base of the eye lashes and/or further up onto the sensitive eye lid skin.  Posterior Blepharitis by contrast occurs at the inner edge of the eyelid next to the eyeball where the meibomian (or oil producing) glands are located.

Now that we know what Blepharitis is and where it occurs, in the next two installments of this series on Blepharitis we will delve further into the different types of blepharitis, what causes each type, what symptoms to watch out for, how these conditions are treated… and maybe even dabble into a little discussion on eyelid parasites!  YIKES!

Stay tuned as we keep an Eye to the Future.

Dr. Keith Roberts is a Louisville-area native, born and raised in Clarksville, Indiana. Upon graduation from Clarksville High School, Dr. Roberts attended Indiana University Southeast earning a B.S. in biology. After completing undergraduate studies in 2004, Dr. Roberts attended the Indiana University School of Optometry, receiving a Doctor of Optometry degree in 2008.

During his tenure at the Indiana University School of Optometry, Dr. Roberts spent time training at Eye Surgeons of Indiana, a tertiary care referral center in Indianapolis, focusing on treatment and management of ocular disease, as well as pre and post-operative care for cataract and Lasik patients.

In addition, Dr. Roberts received training in primary eye care at the Indianapolis Eye Care Center in Indianapolis and the Ireland Army Hospital in Fort Knox, KY. Clinically, Dr. Roberts has a special interest in the treatment and management of glaucoma, as well as non-surgical emergency eye care.

While he is out of the office, Dr. Roberts enjoys spending time with his wife and their two little girls. In addition, Dr. Roberts is an avid sports fan and enjoys fishing when time permits.

Chris Sowder, our office administrator, brings to our practice nearly 20 years of experience. Chris has an Associate of Science degree from Indiana School of Optometry’s optician/technician program. Following school she was an assistant retail manager at a large optical chain, providing her with customer service and optician/dispensing experience. Chris then made a career move to the medical side of optometry as a lead ophthalmic technician for Bennett and Bloom Eye Centers. This experience taught her the importance of early treatment for ocular disease. Most recently, Chris has worked for a busy private practice where she was cross-trained in every department. It has always been Chris’s goal to maximize her college degree and work as an office manager of a locally owned, state-of-the-art Optometry practice. The road she has taken to get here gives her every advantage helping her patients get the most out of their eye care needs. This born and raised Hoosier spent a few years in Bloomington and Indianapolis, but is now proud to call her hometown of Pekin, Indiana home once again. Chris is married and has three school-aged children to keep her busy in her time away from work.

Dr. Nicholas Wolf is a native Hoosier who completed his undergraduate degree in Biochemistry from Indiana University Bloomington and then went on to attend the Indiana University School of Optometry, where he graduated with a Doctorate of Optometry in 2008. He began practicing in Indianapolis before moving to Floyd County in 2012.

During his training at Indiana University, Dr. Wolf received extensive training in eye disease diagnosis and management at Eye Surgeons of Indiana based in Indianapolis as well as at the Dayton, Ohio VA eye clinic.

Dr. Wolf practices full scope optometric care with a special interest in ocular disease evaluation and treatment, including glaucoma, macular degeneration, as well as cataract and laser refractive surgery co-management. Dr. Wolf is also very comfortable and practiced with pediatric populations as well as specialty contact lens fitting. He has continually upgraded his techniques and knowledge in these arenas, as the profession of optometry has expanded, to provide his patients the most advanced possible care.

Dr. Wolf prides himself on his professional, personal, and thorough examinations. He strives to make patients feel welcome and comfortable while he addresses their eye care needs and educates them about their visual system.

Dr. Wolf lives in Floyd county with his wife Edie and is an avid sports fan and counts himself as a loyal Indianapolis Colts and Hoosier faithful. As time permits, he is also an avid woodworker and many of the pieces seen in the office came from his home workshop.

On Friday, July 11, 2014, Precision Family Eye Care had its Ribbon Cutting and is now officially open for business!!

Special thanks to Senator Ron Grooms and Representative Ed Clere for taking time out of their extremely busy schedules to celebrate with us.  We were also joined by Wendy and the rest of the terrific staff from the One Southern Indiana Chamber of Commerce who did a fantastic job of organizing and structuring the event.   Thanks as well to all the 1SI ambassadors and fellow professionals and business owners who graciously spent their Friday afternoon with us and offered us their support and congratulations.  Most importantly, we would like to thank our families for encouraging us, we wouldn’t have gotten this far without your support.

At Precision Family Eye Care, our mission statement is to provide clinical excellence, quality products and unmatched personal and professional services to give our patients the best opportunity for a lifetime of healthy eyes and excellent vision.  We call this area home and look forward to providing comfortable, personalized, and comprehensive care to the wonderful people of this community.

My name is Dr. Nick Wolf and along with my business partner, friend, and fellow optometrist Dr. Keith Roberts, we would like to welcome you to Eye to the Future.  Dr. Roberts and I were classmates at the Indiana University School of Optometry and received our doctorates in 2008.  We are both passionate about this profession and primary care; working constantly to keep abreast of the newest health care developments to allow us to practice at the highest level of care possible.  Over time, however, we found ourselves disillusioned with how the world of eye care was evolving around us and decided to make a change to a way we thought patients should be treated, the way WE would want to be cared for.  As a result, just this summer in May of 2014, we opened a new practice called Precision Family Eye Care in the Floyds Knobs area in southern Indiana near Louisville, KY.  We call this community home and saw the need to bring top of the line eye care to this area.

“The only thing worse than being blind is having sight but no vision.”

–        Helen Keller

At Precision Family Eye Care and especially with the Eye to the Future blog, our vision couldn’t be clearer.  We seek to educate our patients and our readers with the goal of facilitating a better understanding of an organ we all use every single day without fail but have little understanding about the workings of: our eyes.  Through weekly updates, Dr. Roberts and I, along with help from our phenomenal staff will seek to demystify the eye; the way it works, the conditions that can develop, and how to help ensure a lifetime of good vision and healthy eyes.  We will keep you abreast of changes within the industry, new treatments, exciting studies, and anything else related to the eye that give our readers a better understanding of this fascinating organ that is so critical to our everyday lives.

In the professional setting, Dr. Roberts and I love fielding our patients’ questions and this blog will be no different.  We graciously welcome you to email any questions, comments, or topics for future posts to [email protected].  We hope you will join us on this journey as we do our best to keep an Eye to the Future.