Dr Allan Ared
BOptom(Hons) GradCertOcTher(UNSW) FAAO
Blepharitis and dry eye have for years been considered to be two separate diseases; however, courtesy of the extensive work undertaken by the Tear Film and Ocular Surface Society (TFOS)1 we now readily accept that dry eye in both its evaporative and insufficiency forms is part of the natural sequelae from years of untreated lid disease.2
In other words, dry eye is simply the late manifestation of chronic blepharitis3 and we as optometrists can do so much better in eye medicine by preventing damage to the lids in its early forms, instead of waiting to react to that damage once chronicity sets in.
To understand blepharitis correctly we must first understand the term blepharitis, which essentially means that we are dealing with an inflammatory eyelid condition. It is inflammatory due to the nature of the pathology, which often begins with bacterial colonisation of the lids followed by the formation of biofilms (Figure 1) then virulence factor production4 before inflammatory inflicted lid damage.
Figure 1. Accumulation of biofilm in blepharitis
Microblepharoexfoliation or MBE is a novel system for eliminating biofilm from the eyelid margins. Optometrists can easily perform this on patients as an in-office procedure by way of a patented instrument called BlephEx (BlephEx LLC).
BlephEx is a hand-held device that rotates a disposable, medical-grade water-soluble synthetic polymer-sponge which has been presoaked in a commercial eyelid-cleaning solution.
This micro-sponge tip spins at about 2000 rpm. This rotating action along with the lateral-medial-lateral motion of the tool by the operator provides detailed exfoliation to remove inflammatory biofilm and exotoxins, and debulks the bacterial overload. The procedure has also been reported to reduce the population of bacteria to below the quorum-sensing levels that induce virulence factor production.3
MBE is a simple procedure to master. Even after a few treatments, clinicians will have the expertise to handle the most difficult of blepharitis cases. The BlephEx device may be used with either hand and is held like a pen, supported between the thumb and the index finger. The disposable sponge tip needs to be presoaked in cleansing foam. I generally use Blephadex. After soaking, apply the spinning sponge onto the base of the lashes and with steady compression, move along the lid margin in small increments for roughly 25–30 seconds per lid.
The docking station of the BlephEx device has a built-in area for where the Blephadex foam is to be pumped. I have found it much easier to apply the foam over the patient’s inner canthal area and to keep resoaking it from that canthal reservoir (Figure 2).
Figure 2. Inner canthal area used as a foam reservoir of Blephadex
Both upper and lower lids are treated in a similar fashion and a new tip should be used for each eyelid to ensure elimination and disposal of the accumulated bacterial toxins.
Although the treatment is quick and relatively painless, most patients describe a tickling sensation or discomfort due to the quivering of the rotating tip. I use topical anaesthetic before the procedure and in cases of extreme sensitivity a topical anaesthetic gel along the base of the eyelids. After the lids have been meticulously cleaned, the excess foam is flushed out of the eye using a saline eye wash.
Topical therapeutic eye-drops, home lid remedies and over-the-counter artificial tears may only mask the symptoms of dry eye and blepharitis. Regular BlephEx treatment will clean the eyelid margins to eliminate the cause of irritation, offering the most effective results and immediate relief for both the clinical signs and symptoms of both dry eye and blepharitis. I tell patients that a BlephEx lid treatment is similar to a dentist tooth clean, far more effective than home brushing and vital for the effective long-term management and control.
1. Chao W et al. Report of the inaugural meeting of the TFOS i2 = initiating innovation Series: Targeting the unmet need for dry eye treatment. The Ocular Surface 2016; 14: 2: 264–316.
2. Foulks GN. The correlation between the tear film lipid layer and dry eye disease. Surv Ophthalmol 2007; 52: 4: 369–374.
3. Rynerson JM, Perry HD. DEBS: a unification theory for dry eye and blepharitis. Clin Ophthalmol 2016; 10: 2455–2467
4. Knecht LD et al. Serotonin activates bacterial quorum sensing and enhances the virulence of Pseudomonas aeruginosa in the host. EBioMedicine 2016; 9: 161–169.