are you suffering from red irritated crusty eyelids and eyes I'm Dr Michael Chua I'm a board certified ophthalmologist with Puente Hills Eye Care and in this video I'll be discussing blepharitis what it is and how to best treat it so blepharitis is defined as inflammation of the eyelids It's associated with irritation redness crusting of the eyelids and foreign body sensation it's more common in patients with Dermatological conditions such as rosacea and eczema there's two types of blepharitis depending on where it's primarily located anterior blepharitis involves the front side of the eyelid so it usually affects the eyelashes posterior blepharitis is on the back side of the eyelids and primarily affects our meibomian glands which are the oil glands in our eyelids which secrete oil onto our tears these glands are important because that oil in our tear film helps prevent our tears from evaporating and help prevent eye dryness blepharitis is thought to be caused by increased colonization by bacteria as these bacteria replicate they form these organized communities and colonies called biofilms These biofilms are made up of billions with a B of active replicating bacteria and all these bacteria are secreting special sugary Coatings called the glycocalyx that allow the bacteria to adhere to our eyelids and meibomian glands and to communicate with one another as these colonies grow on our eyelids the bacteria begin to release highly inflammatory toxins which stimulate an immune response from us and this is when we can experience red irritated eyelids with dilated blood vessels and crusts at the base of our eyelashes with clogged up my bromine glands unfortunately some people for reasons that doctors are still trying to figure out some people are very sensitive to the bacteria on our skin I mean all of us have bacteria on our skin but for whatever reason some people develop very strong immune responses to these bacteria and exhibit the more severe signs and symptoms of blepharitis now that we have an understanding of what blepharitis is and what causes it let's go through the best treatment options for it the foundation of our blepharitis treatment regimen is eyelid hygiene via warm compress and cleaning the eyelids warm compress is critical to soften meibomian gland oil which allows improved gland secretion during soft I reviewed the best way to apply warm compress in a previous video here but briefly research studies show that we ideally want to heat our meibomian glands to 41 degrees Celsius or 105 degrees Fahrenheit to liquefy all the oily secretions in our glands one of the most consistent efficient and cost effective ways to do this is using an electrical warm compress device such as the aroma season therapy device you can find on Amazon for about 20 minutes once or twice a day by the way I don't have any Financial relationship with any of these companies of the products I'll mention in this video I don't have any affiliate links I don't have any products to sell you the things I'll mention in this video are just things I found that work for me and my patients we then follow up the warm compress with a gentle eyelid wipe to remove and exfoliate all the debris and bacteria from our eyelashes wipes I most commonly recommend are the akusoft lid wipes I like them because they are effective safe and not irritating and pretty accessible they're available at places like Target Walmart CVS Walgreens and online as well there are these wipes that are pretty moistened with eyelid cleanser so all you need to do is to make sure your hands are clean and take out a wipe wrap it around your finger then gently clean your eyelids at the base of the eyelashes most of the flakes and debris are at the base of the eyelashes so you can use gentle side to side motions to free up the flakes to clean your other eyelid you can flip over the wipe wrap it around your finger and do the same process after you're done you can rinse off the solution with water another great lid wipe option particularly for people who have tried the original IQ soft wipes but still have stubborn blepharitis and flakes is to try the akusoft lid scrubs plus these wipes have a Levon formula that continue to work throughout the day so you don't have to rinse your eyelids after using the wipe in terms of frequency I usually recommend for patients to use the warm compress and lid scrub routine once or twice a day if a patient has already tried our lid hygiene routine consistently for a few weeks or months but still having symptoms then we can move on to other prescription options for blepharitis I usually start with an antibiotic ointment such as erythromycin ophthalmic ointment which you can apply to the base of the eyelashes twice a day if a little little bit of ointment gets on the eyeball itself that's totally fine as the ointment is safe for the eyes as well the erythromycin ointment helps to decrease the levels of bacteria on the skin which help to reduce the inflammatory response to the bacteria usually we try our eyelid hygiene regimen with a course of erythromycin for several weeks to a few months and then assess how you're responding to treatment if a patient is suffering from an acute flare-up of their blepharitis with significant eye redness pain and inflammation and we can also consider using a combination steroid antibiotic ointment such as maxitrol or turbadex the steroid in the ointment helps to calm down eyelid inflammation while the antibiotic helps to kill off bacteria this is usually quite effective but we need to be careful when using these steroid ointments as long-term use of steroid medications around the eye for long periods of time such as more than three weeks increases the risk of side effects such as increased eye pressure and early cataract formation if we've tried topical ointments but you're still suffering from blepharitis we can also consider oral antibiotics the most common oral antibiotic for blepharitis historically is doxycycline although Recent research has shown that azithromycin is another promising alternative doxycycline as an antibiotic helps to reduce the number of bacteria on the eyelids and it also has been shown to decrease the activity of Matrix metallopeptidase 9 which is an enzyme that contributes to inflammation so doxycycline has both antibacterial and anti-inflammatory properties the problem with Doxycycline though is that it can cause sensitivity to the Sun so patients need to make sure they wear plenty of UV protection like wide brim hats sunglasses and sunscreen whenever they're out side to prevent sunburns it can also cause GI upset like nausea and diarrhea and it can also cause yellowing of teeth so we usually don't give it to children under eight because the discoloration of teeth can be permanent in kids and doxycycline has also been shown to slow down the growth of Bones azithromycin is another antibiotic that we can use for blepharitis that can significantly improve blepharitis signs and symptoms and in terms of side effect profile the most common side effects are GI upset like nausea diarrhea and decreased appetite although studies comparing doxycycline and azithromycin showed that a significantly smaller percentage of patients experience side effects on azithromycin compared to doxycycline when being treated for blepharitis azithromycin also doesn't cause the teeth discoloration and bone growth slowing that doxycycline does in terms of dosing it'll vary slightly depending on the patient the provider's preference and the severity of the blepharitis standard dosing for doxycycline is 100 milligrams twice a day for six weeks and for azithromycin it's one gram once a week for three weeks but several Recent research studies have shown azithromycin to be as effective or oftentimes more effective than doxycycline and improving blepharitis and meibomian gland dysfunction symptoms while also causing less frequent side effects and it's often cheaper for patients as well so azithromycin is a great first option as an oral antibiotic for treating blepharitis okay so we talked about the most effective treatment options of blepharitis from lead hygiene to topical antibiotics to oral antibiotics the one last topic of blepharitis I'll talk about is Demodex blepharitis now Demodex is the name of mites that many people just naturally have living on their skin these Demodex mites inhabit the hair follicle and sebaceous glands of human skin including the island and all it sounds kind of gross that we have these mites living and reproducing in our eyelashes but it's really quite common a study from 2014 sampled different patient eyelids and found a prevalence of Demodex in 69 of 31 to 50 year olds 84 in patients older than 60 and 95 in patients 70 years of age and older while Demodex mites are usually harmless in low numbers and overgrowth of these mites can lead to various skin and eyelid issues including blepharitis now the blepharide is caused by Demodex is similar to the typical blepharitis we see like itching and irritation of the eyelids redness and swelling of the eyelid margins encrusting and flaking of the eyelid skin the distinguishing feature we can see on slit lab examination is cholerets these cylindrical deposits look like waxy plugs around the base of the eyelashes at the lid margin you can see how colorat's different appearance compared to flaky skin on the lid margins which you see with other types of blood varieties so when we see cholerets on exam we know that we need to treat Demodex blepharitis and we need to adjust our treatment strategy slightly the Mainstay of Demodex treatment is eyelid wipes with tea tree oil which has been shown in multiple clinical trials to significantly improve demidex blepharitis akusa the eyelid wipes I mentioned earlier also manufacture and oust Demodex formula which features tea tree oil so that's what I recommend to patients who are diagnosed with Demodex blepharitis if patients with them varieties have tried tea tree oil wipes and are still struggling with symptoms a good topical option to try is Ivermectin cream historically Ivermectin is a medication that has been used to treat parasitic infections such as warm infections or scabies this 2022 study from the journal cornea showed that using topical one percent Ivermectin cream applied to the eyelids for 15 minutes once a week in addition to the typical eyelid hygiene of eyelid wipes significantly improve symptoms eyelid debris redness and swelling compared to eyelid hygiene alone the only reported side effect was mild eyelid irritation so I think Ivermectin is a really good option for Demodex blepharitis there's actually also been a new eye drop specifically for Demodex blepharitis called extemv which was approved by the FDA in July 2023. randomized phase 3 clinical trials showed that xdemv was effective at clearing out Demodex and improving blepharitis symptoms the most common reported side effect was eye stinging and burning when eye drops are placed in the eye which was reported in about 10 percent of patients it's incurred urging that we have this new option for patients with Demodex blepharitis but I'll still be waiting for further studies after the release of the medication to evaluate its Effectiveness and safety in real world scenarios the other point to consider with a medication is that the company's CEO announced that it will cost a whopping 1850 for the treatment usually when medications are first launched pharmaceutical companies have coupons or work with insurance companies to help lower the out-of-pocket cost of patient but the Steep price tag for exempty will make the medication difficult to access for many patients okay so we reviewed the causes of blepharitis as well as the best treatment protocols for it the foundation of our blepharitis treatment regimen is eyelid hygiene consisting of warm compress and eyelid wipes once or twice a day for more moderate cases we may introduce topical antibiotics such as erythromycin or for acute flare-ups we can consider a steroid antibiotic combination ointment like maxitrol and for more severe cases that aren't responding to topical treatment we can consider oral antibiotics such as azithrom and lastly if there's a suspicion for Demodex blepharitis we make sure to incorporate a tea tree oil-based wipe like the akusoft Demodex wipe and consider Ivermectin cream for more severe cases I think that's enough for this video but if you find the information in this video helpful please give us a thumbs up and subscribe to the channel for future updates and if you live in the Los Angeles Orange County or Inland Empire area and want to be examined for blepharitis or dry eye feel free to visit our website or give our phone number a call to make an appointment today I'm Dr Michael chuo with Puente Hills eye care see you next time