Blepharitis and Dry Eye: The Chicken or the Egg?

Blepharitis and Dry Eye: The Chicken or the Egg?

For many years, blepharitis and dry eye disease (DED) have been thought to be two distinct diseases, and evaporative dry eye distinct from aqueous insufficiency.

Consider the “chicken-and-egg”, a metaphoric adjective describing situations where it is not clear which of two events should be considered the cause and which should be considered the effect. As eye care practitioners we tend to focus on the immediate presenting problem and not what preceded it. The two conditions, DED and blepharitis have multiple overlapping symptoms and pathologies intertwined. With a re-evaluation of the existing evidence and intuitive reasoning, is non-Sjogren’s DED simply the late form and late manifestation of one disease, blepharitis?

DED is often the natural sequelae of decades of chronic blepharitis. In 1946, Phillip Thygeson, MD, described blepharitis as, “a chronic inflammation of the lid border”. In spite of the very nature of the word blepharitis (blepha = lid, ritis = inflammation), inflammatory lid disease lacking lash and lid debris would often lead practitioners away from the diagnosis of blepharitis, as if having “scurf” was a prerequisite for having the disease. While terms such as anterior or posterior blepharitis, staphylococcal blepharitis or seborrheic blepharitis as distinctions are rarely isolated, often overlapping and do not serve to accurately describe the stage or duration of disease (1). Normal lid margin flora bacteria, primarily Staphylococcus aureus and Staphylococcal epidermidis, overcolonise the lid margin within a structure known as a biofilm, the most basic of bacterial survival strategies (2) . The eyelid is the perfect environment as biofilms form wherever there is the combination of moisture, nutrients and a surface (3). Biofilms create a nutritious food supply for the ubiquitous Demodex mite in the form of a polysaccharide and endogenous bacteria (4). The biofilm and Demodex mites never go away; the biofilm thickening, and Demodex population increasing with age, producing increasing quantities of bacterial virulence factors, chemokine release and thus, increasing inflammation.

Belonging to the arachnoid species, Demodex mites live in the base of the eyelash follicles and meibomian glands. Lacking an anus, Demodex mites store their faeces internally in a crystallised form until they decompose, releasing their internal contents onto the host eyelid margin (4). The combination of the biofilm bacterial virulence factors, and large numbers of dying Demodex mites creates a domino effect, first follicular inflammation, then meibomian gland dysfunction, lid wiper epitheliopathy, aqueous insufficiency through inflammatory damage to the accessory lacrimal glands of Wolfring and Krause, destruction of the eyelid anatomy, and ultimately ocular surface disease.

Antonie van Leeuwenhoek made the first known microscopic observation of a biofilm in 1684; oral bacteria within the scurf of a man’s teeth (5). Over 100 years ago, no one brushed their teeth or practiced any form of regular oral hygiene, chronic gingivitis preceded eventual tooth loss and dentures were the norm. Dentistry has effectively educated the world on regular and routine oral hygiene and we visit their practices for regular cleaning with the dental hygienist to remove biofilms from our teeth and gums. With nearly 337 million people suffering from dry eye syndrome worldwide (6), to quote Benjamin Franklin, “an ounce of prevention is better than a pound of cure”. The pound of cure is expected to generate US$4.5 billion by 2020. Can and should the eye care industry prevent dry eye through effectively treating blepharitis and eventual meibomian gland loss before our patients are symptomatic? Is dry eye and blepharitis one entity, that is dry eye blepharitis syndrome or DEBS, reflecting, in fact, a single disease process rather than two distinct processes? As primary eye care practitioners, optometrists have the opportunity to play a key role in the prevention, not just the treatment of dry eye disease, by supporting the increasingly strong argument that blepharitis and dry eye should be treated and prevented by early and routine biofilm removal with microblepharoexfoliation and regular and routine eyelid hygiene.

References

1. Bernardes, T.F. and A.A. Bonfioli, Blepharitis. Seminars in Ophthalmology, 2010. 25(3): p. 79-83.

2. Brothers, K.M., et al., Dexamethasone diffusion across contact lenses is inhibited by Staphylococcus epidermidis biofilms in vitro. Cornea, 2014. 33(10): p. 1083-7.

3. Rynerson, J.M. and H.D. Perry, DEBS – a unification theory for dry eye and blepharitis. Clin Ophthalmol, 2016. 10: p. 2455-2467.

4. Moran, E.M., R. Foley, and F.C. Powell, Demodex and rosacea revisited. Clin Dermatol, 2017. 35(2): p. 195-200.

5. Christersson, L.A., J.J. Zambon, and R.J. Genco, Dental bacterial plaques. Nature and role in periodontal disease. J Clin Periodontol, 1991. 18(6): p. 441-6

6. Cannady, K. Dry Eye Products Market Expected to Generate $4.5 Billion by 2020. 2016 [cited 2017 18 July]; Available from: https://market-scope.com/pressrelease/ dry-eye-products-market-expected-to-generate-4-5-billion-by-2020/.

*Lachlan Scott-Hoy is a well-known presenter and owner of Innovative Eye Care in Australia. He has a special interest in orthokeratology and contact lenses and is director of Innovative Contacts, a company which specialises in the design, supply, and advice for fitting RGP contact lenses

Back to blog

5 comments

Dobar dan, moj upit o tome kako dobiti kredit za kupnju kuće od nekretnina počeo je pozivom, nazvao sam Davidson Albert Company, danas sam jako sretan i Bog blagoslovio Davidsona Alberta Kontakt e-mail: {Davidsonalbertloan@gmail.com }

Zovem se Marijana, iz HRVATSKE sam, zadnjih pet mjeseci sam tražila pravu kreditnu tvrtku od koje bih mogla dobiti kredit kako bih mogla kupiti kuću kakvu sam htjela. Dugoročno, bilo je hrpa prijevara zbog kojih sam im povjerovao i na kraju dana su mi uzeli novac bez da su mi dali išta zauzvrat, čak ni 1 euro na moje ime, izgubio sam svaku nadu, bio sam zbunjen i frustriran, nikad nisam želio imati ništa s online tvrtkama za zajam pa sam otišao posuditi novac od prijatelja. Ispričao sam sve što se dogodilo i rekla mi je da mi može pomoći pronaći tvrtku za zajmove koja mi može dati bilo koji iznos zajma koji mi treba i po vrlo niskoj kamatnoj stopi od 3%, također mi je rekla da je upravo dobila zajam od uputio me kako se prijaviti za zajam baš kao što mi je rekla, aplicirao sam s njima putem e-pošte: (davidsonalbertloan@gmail.com), nikad nisam vjerovao, ali sam pokušao, i na moje najveće iznenađenje dobio sam zajam u roku od 24 sati, nisam mogao vjerovati, ponovno sam sretan i bogat i hvala Bogu da takve kreditne kuće još postoje na ovim prevarama posvuda, savjetuju svima koji trebaju posuditi kredit putem e-maila (davidsonalbertloan@gmail.com). Nikada te neće iznevjeriti i tvoj život će se promijeniti kao i moj. Brzo kontaktirajte (davidsonalbertloan@gmail.com) danas i uzmite svoj zajam od njih. Obavezno kontaktirajte DAVIDSON ALBERT LOAN COMPANY za vaš kredit, jer sam uspješno dobio svoj kredit od ove tvrtke bez ikakvog stresa. Posjetite njihovu e-poštu. (davidsonalbertloan@gmail.com)

HOW TO GET A QUICK AND AFFORDABLE LOAN

Investment is one of the best ways to achieve financial freedom. For a beginner there are so many challenges you face. It’s hard to know how to get started. Trading on the Cryptocurrency market has really been a life changer for me. I almost gave up on crypto at some point not until saw a recommendation on Elon musk successfully success story and I got a proficient trader/broker Mr Bernie Doran , he gave me all the information required to succeed in trading. I made more profit than I could ever imagine. I’m not here to converse much but to share my testimony; I have made total returns of $10,500.00 from an investment of just $1000.00 within 1 week. Thanks to Mr Bernie I’m really grateful,I have been able to make a great returns trading with his signals and strategies .I urge anyone interested in INVESTMENT to take bold step in investing in the Cryptocurrency Market, you can reach him on WhatsApp : +1(424) 285-0682 or his Gmail : BERNIEDORANSIGNALS@GMAIL.COM, bitcoin is taking over the world, tell him I referred you

Dave allen

HOW TO RECOVER FROM CRYPTOCURRENCY SCAMS.

In the new world of Cryptocurrency, losing funds to online Ponzi schemes has really been a nightmare to bitcoin investors, as most of them end up falling prey to these schemes. Investors have now been the common target to these internet crooks, leaving them losing most of their hard earned funds, in some situations most of them are left in large debts.
However after losing your crypto to scammers, all hope is not gone. There is a professional recovery team, CAPTAIN WEBGENESIS. The team is specialized in helping individuals retrieve their lost or stolen funds. CAPTAIN WEBGENESIS is a team with a high record track of recovery success, thus they are the highly recommended Recovery company to help scam victims recover their lost funds.

More Info;
WhatsAp; +1 (701) 314-2729.
Mail Add; Captainwebgenesis@hackermail.com
Web Page; Www.captainwebgenesis.com

Rosie Eleanor

HOW TO RECOVER FROM CRYPTOCURRENCY SCAMS.

In the new world of Cryptocurrency, losing funds to online Ponzi schemes has really been a nightmare to bitcoin investors, as most of them end up falling prey to these schemes. Investors have now been the common target to these internet crooks, leaving them losing most of their hard earned funds, in some situations most of them are left in large debts.
However after losing your crypto to scammers, all hope is not gone. There is a professional recovery team, CAPTAIN WEBGENESIS. The team is specialized in helping individuals retrieve their lost or stolen funds. CAPTAIN WEBGENESIS is a team with a high record track of recovery success, thus they are the highly recommended Recovery company to help scam victims recover their lost funds.

More Info;
WhatsAp; +1 (701) 314-2729.
Mail Add; Captainwebgenesis@hackermail.com
Web Page; Www.captainwebgenesis.com

Rosie Eleanor

HOW TO RECOVER FROM CRYPTOCURRENCY SCAMS.

In the new world of Cryptocurrency, losing funds to online Ponzi schemes has really been a nightmare to bitcoin investors, as most of them end up falling prey to these schemes. Investors have now been the common target to these internet crooks, leaving them losing most of their hard earned funds, in some situations most of them are left in large debts.
However after losing your crypto to scammers, all hope is not gone. There is a professional recovery team, CAPTAIN WEBGENESIS. The team is specialized in helping individuals retrieve their lost or stolen funds. CAPTAIN WEBGENESIS is a team with a high record track of recovery success, thus they are the highly recommended Recovery company to help scam victims recover their lost funds.

More Info;
WhatsAp; +1 (701) 314-2729.
Mail Add; Captainwebgenesis@hackermail.com
Web Page; Www.captainwebgenesis.com

Rosie Eleanor

Leave a comment