Blepharitis
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3328 (Published 23 May 2012) Cite this as: BMJ 2012;344:e3328
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Many thanks for your interest in our article. Our aim in producing a ‘10-Minute Consultation’ piece was to provide the generalist with a broad overview of a common and troublesome condition. By definition, the ‘10-Minute Consultation’ should be brief, so we did not set out to provide a comprehensive review of the subject complete with ongoing controversies regarding pathophysiology and treatment. Rather than simply stating that blepharitis is a chronic condition, as you suggest, we gave tips for making the diagnosis, highlighted pitfalls in terms of the differential diagnosis and suggested a treatment regime.
As you correctly point out, the hospital eye service is increasingly oversubscribed and it would be unsustainable for all blepharitis patients to be referred. Consequently, we explained that most patients with blepharitis can be managed conservatively in the community, but in cases of poor response or doubts in the diagnosis, a secondary referral is appropriate.
With regards to Demodex folliculorum, there is debate as to its role in blepharitis. Demodex is an extremely common commensal, which ordinarily does not elicit any pathological response. A recent meta-analysis demonstrated a significant association between Demodex and blepharitis (1), but it should also be pointed out that similar, high prevalences of Demodex infestation have been found in both patients with blepharitis (28.8%) and normal control subjects (26.7%) (2). The general consensus is that in cases of blepharitis where robust attempts at conventional treatment fail, investigation for demodecosis may be appropriate. These patients fall into the category which is appropriate for secondary ophthalmic referral. We would not advocate that human patients should consult a vet.
Clearly, we realise there are controversies and questions which have not yet been answered. Many comprehensive papers exist in the scientific literature to address these issues, including an excellent Cochrane review published earlier this year (3). Further work will hopefully elucidate ways in which blepharitis can be cured instead of just controlled.
Dr Andrew Turnbull
Dr Martin Mayfield
References:
1) Zhao YE, Wu LP, Hu L, Xu JR. Association of blepharitis with Demodex: a meta-analysis. Ophthalmic Epidemiol. 2012 Apr;19(2):95-102. Epub 2012 Feb 24.
2) Kemal M, Sümer Z, Toker MI, et al. The prevalence of Demodex folliculorum in blepharitis patients and the normal population. Ophthalmic Epidemiol. 2005 Aug;12(4):287-90.
3) Lindsley K, Matsumura S, Hatef E, Akpek EK. Interventions for chronic blepharitis. Cochrane Database Syst Rev. 2012 May 16;5:CD005556
Competing interests: No competing interests
We agree with T Graham Edwards(1) that Demodex folliculorumis a commensal found in normal people as well. According to Galvis-Ramírez V(2) it is a parasite found in people without ocular lesions as well, but, it is more frequent and has a higher parasite burden in patients with blepharitis2. Their results, thus, suggested the need for investigating the presence of D. folliculorum in all patients suffering from blepharitis, especially in cases where cylinder-type scaling has been observed in their eyelashes2. According to a recent Cochrane review the exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low-grade infections of the ocular surface with bacteria, infestations with parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea3. Though the current article gives the treatment, but according to Cochrane Review, “Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis3. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness3. Further research is needed to evaluate the effectiveness of such treatments”3.
References:
1. http://www.bmj.com/content/344/bmj.e3328/rr/609704
2. Galvis-Ramírez V, Tello-Hernández A, Álvarez-Osorio L, Rey-Serrano JJ. [The prevalence of Demodex folliculorum infection in patients attending a general ophthalmological consultation]. Rev Salud Publica (Bogota). 2011 Dec;13(6):990-7. [Article in Spanish]
3. Lindsley K, Matsumura S, Hatef E, Akpek EK.Interventions for chronic blepharitis. Cochrane Database Syst Rev. 2012 May 16;5:CD005556.
4. Turnbull AM, Mayfield MP. Blepharitis. BMJ. 2012 May 23;344:e3328. doi: 10.1136/bmj.e3328.
Competing interests: No competing interests
Dear Editor,
I felt disapointed after reading the Ten Minute Consultation concerning Blepharitis,(Turnbull AMJ & Mayfield MP, BML Vol 345 No7872 1st September 2012 General Practice Page 40-41.) because the authors have not progressed beyond repeating that it is a chronic disease. Controversy has existed in the profession for many years concerning the cause of this common condition as to whether Demodex Folliculorum infestation is implicated or not.
Many state that this organism, not dissimilar to the scabies mite, is merely a commensal.It is an Arachnid with a two week life cycle, which paracitises sebaceous glands, meibomian glands and the follicles of eyelashes.
The conflicting views are clearly explained in Albert & Jakobiec's Principles and Practice of Opthalmology.
It may seem that this is a minor condition and the authors suggest that patients should only be referred to see an Opthalmologist if they present with complications. It is however extremely common and affects many millions of persons world wide, especially the elderly and it results in considerable morbidity and distress to suffers as well as the costs of repeat prescriptions for dry eyes etc. Interestingly it also lies between the disciplines of Dermatology and Opthalmology, both of which are 'fully occupied' and not looking for extra work. And where is the demarkation between the two ?
Should I refer patients to the Opthalmology OPD or to the Dermatology Department ? Or should they see their Vet, who has been treating demodecosis in animals successfully for many years with acaricides.? !
The pictures obtained by Frank English and Others in Brisbane in 1990, using the scanning electron microscope are the most compelling, regarding a condition from which I used to suffer.
As an added bonus, several other lesions affecting my forehead that I had been assessing as incipient actinic keratoses and contemplating seeing my GP for cryotherapy, have also disappeared.
Yours sincerely,
Graham Edwards
References: 1, Chan AS & ColbyKA Lid Inflammations Albert & Jakobiec's Principles and Practice of Opthalmology 3rd Edition Philadelphia Saunders Elsevier 2008 Pages 628-635
2, English FP Zhang GW McManus DP & Campbell P American Journal of Opthalmology Vol 109 No 2 Page 239-240 Feb 1990.
ps., Knowing your keeness in the use of images in your Journal, it might be possible to reproduce the images from the American Journal of Opthalmology with the appropriate permission, should it be forthcoming. I have attached the photos that I took from the Journal, to encourage you with this.
Dr T G Edwards
Locum in Greneral Practice
+44(0)1243 514652
+44(0)7831 139062
ffolletts Birdham Chichester West Sussex PO20 7QL
tg.edwards@btinternet.com
Competing interests: No competing interests
Re: Blepharitis
I would like to report a case of chronic blepharitis treated successfully with pure petroleum jelly (Vaseline).
The debate over the significance of demodex involvement in blepharitis (and rosacea) has reached an impasse because, in part, of the absence of a simple test for infestation available in the surgery. Referral for treatment is therefore not possible, and the debate over significance continues.
The available treatments for mite infestation are too toxic to use without evidence of infestation.
If a simple treatment without known side effects could be envisaged then it would surely be possible to treat without evidence of infestation. Hence the choice of pure petroleum jelly to preclude air from the glands and discourage the mite.
I have had some less dramatic success with suggesting the same approach for patients with rosacea (petroleum jelly applied to the skin overnight) and so there may be reason to continue this advice.
Yours sincerely,
John Laband
Competing interests: No competing interests