Case Review: Blepharitis Management

Speaker 1 (00:00): Tarsus Pharmaceuticals Incorporated applies proven science and new technology to revolutionize treatment for patients across several therapeutic categories, starting with eye care. Their lead product, XDEMVY Lotilaner Ophthalmic Solution 0.25% is FDA approved in the United States for the treatment of Demodex blepharitis. Learn more at tarsusrx.com.

Sila Bal (00:45): Welcome to Pupil Pod, where we use clinical cases to guide discussions on board review topics. I'm your host, Sila Bal, and my guest today is Dr. Caroline Watson. Dr. Watson is a refractive cataract and cornea surgeon with expertise in ocular surface disease. Dr. Watson, thank you for joining me today.

Caroline Watson (01:04): Thank you for having me. I’m excited. This is my first Pupil Pod.

Sila Bal (01:09): It hopefully is not your last. We're so excited to have you.

Caroline Watson (01:13): I'm excited. This is going to be fun.

Sila Bal (01:15): It's going to be super fun. Our favorite topic, our favorite thing to deal with, let's jump right into the case. So, this is a 64-year-old woman who presented with chronic burning, fluctuating blurry vision, tearing, and irritation in both eyes. She says her eyes are often worse in the morning and when reading or using the computer for long periods. She has been treated intermittently with everything from artificial tears to short courses of topical antibiotics, but her symptoms continue to recur. On exam, her visual acuity is 20/25 OU. The tear film is unstable. There's debris at the lash base. There's mild lid margin telangiectasias, capped meibomian glands, collarettes, and trace inferior punctate epithelial erosions. Okay, this is so common in our clinics, and I feel like this is most of our patients in this age category, but the terminology can get confusing pretty quickly. So, to start us off, how do we even define blepharitis?

(02:20): How do you think about it or break it down conceptually in your mind for our residents and fellows out there?

Caroline Watson (02:26): Yeah. Well, to start, all of these symptoms are not mutually exclusive. They have a lot of overlap between disease entity. So, blepharitis, if I had to define it as kind of a chronic inflammatory disease of the eyelid margin, it's really a spectrum. It involves the lashes, the lid margin, the meibomian glands, and then ultimately the ocular surface, which is how they find me, right?

Sila Bal (02:57): Yes.

Caroline Watson (02:59): I guess if you're going to be rigid about definitions, you can talk about anterior blepharitis, which is more of the eyelashes, or you can talk about posterior blepharitis. I don't really divide them because there is so much overlap and it's not like you're going to treat them much differently; I guess. Not really. I don't, not in real life. So, most patients have features of both. I think that as a refractive cataract surgeon who utilizes a lot of premium lens technology, it's really important because it's linked to tear film dysfunction, which ultimately causes ocular surface disease. So, I think a lot of people just categorize all of this under dry eye disease when there's actually multifactorial reason that they're having these symptoms and manifestations on their exam.

(04:02): I think the frustrating thing for patients is that technically we don't have a solid cure for all of the things. So, people get bounced around or they get the kitchen sink thrown at them when they're trying to just feel normal. And I think that leads to maybe some distrust in providers or they kind of give up and they're just miserable. I mean, this is a really serious thing and it's so common. And as a refractive surgeon, you have to pay attention to this because there's such a big push for everyone to really buy into advanced technology lenses and even phakic IOLs or whatever you're doing. And if you don't have a healthy tear film and lid margin, you're going to have unhappy patients and that's where the struggle comes in for practices and doctors. So that's pretty much what I think.

Sila Bal (05:09): Yeah. I mean, we've all had those patients that come in and they're like, "I've been using artificial tears every hour. It does nothing for me. It doesn't help me at all." And you look at them and you're like, "Well, has anyone ever diagnosed you with rosacea?" Because their nose is like, they have very significant rhinophyma. I mean, it's rosacea from across the hall, but nobody has ever stopped to think that maybe this is rosacea. And that's just one example. So, what are some of the historical features that you ask these patients to tease out? Oh, is this aqueous deficiency dry eye where tears and topical therapy might help or is this some sort of underlying rosacea or maybe just meibomian gland dysfunction where we need more warm compresses, eyelid management? What are some of the things that you would want to ask patients about their history?

Caroline Watson (06:01): Probably starting off with what you mentioned, do you know what rosacea is? Have you ever had facial rosacea? Really taking into consideration their Fitzpatrick type and have they worn contact lenses before? Have they ever tried and failed treatments, either conservative or prescription? Have they ever had refractive surgery? Have they had styes before? I think there's just so many layers of digging deep into this problem. You really have to learn how to pinpoint and figure it out. My main thing is what is your biggest symptom? What's bothering you the most? So, if I can kind of narrow it down to that, I know I can get these people to a better baseline because they are just hyper aware of their eyes all day long. Can you imagine? I have some dry eyes. I had LASIK whenever, 15 years ago, so I had that, but I'm not walking around and waking up thinking about how miserable my eyes feel.

(07:14): So, I can't imagine people who have to deal with the severity of that every day. So, I really try to encourage them, listen, we'll figure this out one way or another. Probably not going to go away altogether, but I'm going to string together more good days than bad days.

Sila Bal (07:31): Absolutely. And the more good days than bad days and we're in this together and listening to the complaints, I think as surgeons who treat ocular surface disease, that is probably the most important advice you can give because a lot of these patients are dismissed because a lot of docs are like, oh, it's dry eye, do some artificial tears, you'll be fine without getting to the root cause and without hearing what the patient is really experiencing. And no, I could not imagine. If my eyes– I also, I had PRK, I have some mild dry eye, especially when I'm in extreme climates, but I could not imagine having to deal with that day in and day out. And patients can tell when you care and you want to help them figure out their pathology, but it's so much more complex than just like use some artificial tears and you'll be fine.

(08:24): Speaking of complexity, okay, I still struggle with this, so I just want to hear your thoughts. The collarettes versus scruff and distinguishing between scruff and collarettes. Sometimes patients come in and you're like, "That's definitely scruff. That is not Demodex. That is staph that needs to be treated." But how do you think through the difference between the two? And obviously there's overlap. There's always overlap.

Caroline Watson (08:48): Sure. I think the scurf or what did you say? Scarf?

Sila Bal (08:55): Listen, don't listen to the way I say anything. I also call Demodex, sometimes I call it “DEEMODEX”, like a demon. You cannot undo it in my head. It just is the way it is.

Caroline Watson (09:08): Okay. So, the scurf, they're like greasy little flakes of skin and debris, and that's more of an anterior seborrheic staphylococcal origin. The collarettes are more on the lash base and it's like a little yellow cuff of basically excretions from either Demodex mites or maybe even things we don't fully understand about collarettes. And it really does matter where they're located because it can kind of guide you a little bit. But the collarettes on their own are really important as far as diagnosing Demodex blepharitis, which thankfully you have an awesome treatment for right now. And I've had a lot of success with it, and I still think we're learning so much about it, but what a huge step in the right direction without need for long-term pharmaceutical use, which is huge. We don't want to put patients on drops forever and ever and ever. And not to go on a tangent, but it's just like interventional glaucoma versus long ago drop therapy.

(10:41): We are entering a space in a time where I think we're trying to be more efficient and diligent with our treatment for these patients because we don't want to put the responsibility on them.

Sila Bal (10:54): Absolutely. And we know that there are compliance issues. I mean, speaking about interventional glaucoma, it's like SLT is essentially as successful as topical therapy, not because it's doing anything more than topical therapy, but that we get rid of the compliance issue.

(11:11): So, same thing with this. Can you tell us a little bit about the treatment that you're alluding to for Demodex, kind of what we traditionally used to recommend for patients and what we're now able to offer patients?

Caroline Watson (11:25): Yeah. Well, I mean, I'm sure you know when we were residents, we were taught to use lid wipes, baby shampoo on our fingers and hot compresses maybe, a tea tree oil even. And now we know that that's not the best, especially the baby shampoo because it actually removes the healthy oils from the eyelid margin in the surface. So, we don't want that. I still have patients that come in here and there who were told or they did their own online Google search, and they did that on their own. They're self-treating. I'm like, "Please stop."

Sila Bal (12:09): I know. Or you have the patients, I inherited a lot of patients and they're like, "No, this is what I was always told to do." And it's really delicate to have that conversation and be like, "I know, but we do have better things now that can help you that are less harmful and still just as easy to use." So, it's navigating that.

Caroline Watson (12:30): Yeah, it is a careful conversation. So thankfully two years ago, almost three years ago, Tarsus came out with XDEMVY and I use it daily. I prescribe it daily. I mean, it works. I mean, we've had such amazing, consistent results from it. So, it's a twice daily dosing for six weeks. And like I said, we're getting a lot of data. Gosh, you and I have had a partnership with Tarsus since before, long before XDEMVY came out. And I remember just kind of waiting and waiting and waiting like, "Oh, it's coming. It's coming. We've got something coming. Hold tight." I kept telling people, "Just wait, just wait. It's close."

Sila Bal (13:21): Now we have it.

Caroline Watson (13:22): We have it. Yeah, no, it works well. And then I do use it in combination with some other conservative, I guess, treatments. So typical lid scrubs, and I'm going to plug our friend here, Ashley Brizette. I use their daily practice foam cleanser because it's really gentle. So, I use that alongside all these other things, and it's just a nice little morning, night routine for these patients to get in the habit of doing.

Sila Bal (13:55): No, absolutely. Whenever I think about my patients with blepharitis, let's say that we've ruled out inflammatory disease or rosacea and we're like, "Okay, this is mostly Demodex that we're dealing with right now." It's always some artificial tears just to help support the ocular surface, warm compresses to help prevent any meibomian gland dysfunction. And then XDEMVY, it's amazing. Twice a day, six weeks, and then pair that, like you said, with the lid wipes. And you really just need to treat it long enough to break the cycle. You just need to get through those six weeks. And then yes, you'll have some refractory cases, or you'll have patients that have recurrence or relapse of symptoms later, but the fact that we're able to treat them for just a finite amount of time and most patients recover and feel, they feel better subjectively. Objectively, we see it. There's less collarettes, there's less disease burden, but subjectively they're thrilled.

(14:52): They feel maybe not 100% because again, this is a chronic condition that they're dealing with and it's multifactorial, but they do feel a lot better.

Caroline Watson (15:01): Yeah, it makes a difference. And a lot of times I'm getting these patients for cataract surgery and I find it, and I am a stickler for optimizing the lid margin ocular surface prior to cataract surgery because I don't want unhappy patients. And I think it's just a concept that's lost on a lot of our colleagues that ignoring such a huge component of our visual acuity potential is probably not the best. I mean, I know it can be time-consuming to have these patients who you may not know exactly what's going on, but we can all keep learning and we can all do better for those patients and help them. And I think that it's problematic if you aren't paying attention to that.

Sila Bal (16:04): So, since we're on the topic, can you tell us a little bit about how you manage those surgical patients? So, let's say you have this patient come in and she's also getting worked up for cataracts. How do you have that conversation with her? Do you treat the ocular surface, bring her back, and then keep bringing her back when you feel good, then you do your testing again and you repeat your biometry? How does that flow look for you?

Caroline Watson (16:33): If I have somebody who we do need to treat more aggressively, maybe they're motivated to have a toric or a premium lens or something like that, and you need to make sure your biometry is as accurate as possible for everybody, but especially for those because you don't want to have a refractive error when you're trying to guarantee a pretty solid outcome. And if I find something that needs to be taken care of, we just have a conversation. I say, "Listen, you've got X, Y, Z. We need to take care of that and get your eyes ready for surgery." I don't really even feel like it delays me that much. A couple of weeks we can get them started on these things. And at this point, I can kind of pick up on something more severe just by looking at them. I can tell if they've got mild neurotrophic keratitis.

(17:34): I can just kind of tell just by the history and by how frequently I look at it and see it. At this stage, I can pretty much figure out who's going to take a little bit longer, who's going to need more aggressive therapy to get ready, and then who's going to be fine doing conservative treatment, treating the blepharitis and prepping the tear film. So, I don't think really anybody pushes back too much. They're just grateful that I'm being thorough and they want to see well. So, it's not that burdensome to do those things. Sila Bal (18:14): No. And especially if you set that, it's always better. I over counsel all my patients because it's better to under promise and over deliver than to over promise and under deliver. So, anyone with even a little bit of VMA, I'm like, "You could have post-op CME," even though I've, knock on wood, only seen it in a very few number of patients in those cases, but I just prepare them. And the same thing with the ocular surface. When they have dry eye, I'm like, "We need to be really aggressive with your treatment before the surgery. After the surgery, your dry eye is going to get worse temporarily and then it will get better." I tell them about how I had PRK, and I thought I would be better after a week and for six months I was using artificial tears and being really dramatic. Now I'm fine, obviously.

Caroline Watson (19:04): No, not you.

Sila Bal (19:05): No, of course. Exactly. I was closing one eye and then the other and checking my vision and knowing that I tell all my patients not to do that, and I was doing that and texting people and being like, "It's blurry in my left eye. Ridiculous." So, we all have kind of experienced some level of that, so they definitely are grateful. And then I usually try to bring them back after a month or so. So, I try to get them that full month. I don't know if you do anything different, but I feel like a good month of–

Caroline Watson (19:32): A couple weeks to a month, that's pretty much when we're booking them for their first eye anyway. And then we'll bring them back in and repeat everything and make sure we have the most up-to-date measurements, and they seem to appreciate that. So, like I said, I haven't had anyone get funny about it.

Sila Bal (19:48): Totally. Okay. So, switching gears a little bit to the inflammatory blepharitis, like the rosacea patients, doxycycline is incredible. I highly recommend it to my ocular rosacea patients. Are you using other therapies? Do you like doxy? Do you like topical azithromycin? How do you kind of talk to those patients? Walk them through that.

Caroline Watson (20:14): Yeah, so I actually do a lot of IPL, so not as frequent with the doxy. And it's interesting you mentioned that, but there's a lot of exam and exam overlap with Demodex lid margin appearance versus ocular rosacea. So, I find that if you see even a couple of collarettes like grade one, they may have telangiectasia, so you're like, "Do they have rosacea two?" You got to treat the Demodex first to eliminate that and then bring them back. And if the telangiectasias are still there and they kind of fit that criteria, you know, okay, this is ocular rosacea, but a lot of times it'll resolve. Those inflamed blood vessels will go away. So, it can be a little bit of a masquerader, but if it's real rosacea, which I'm sure you see a lot because everybody's in the sun, I just do IPL on them and it works great. It really does.

Sila Bal (21:33): That brought me to my next question, which is the in-office treatments. So, you love IPL. Is there anything else that you like recommending to your patients? LipiFlow, what are some of the pros and cons of the in-office treatments?

Caroline Watson (21:47): Just recently, Sight Sciences started having insurance cover TearCare. I think they're still waiting on all the MACs to be in agreement. So, I used to do a lot of that, which I liked. And then I would combine that with IPL, which is great, but it's still out of pocket, so that's kind of a hurdle. I've never used LipiFlow actually. I've just never had one available. I'm not opposed to it. I just don't have any experience with it. And that's really kind of what I use right now. That's what I have access to.

Sila Bal (22:26): I'm going to use this as a natural transition for us to move things over to our sponsors. So, you'll get a brief message from our sponsors and then you'll be back with us on the Pupil Pod.

Speaker 1 (22:42): Tarsus Pharmaceuticals Incorporated applies proven science and new technology to revolutionize treatment for patients across several therapeutic categories, starting with eye care. Their lead product, XDEMVY Lotilaner Ophthalmic Solution 0.25% is FDA approved in the United States for the treatment of Demodex blepharitis. Learn more at tarsusrx.com.

Sila Bal (23:07): All right, Dr. Watson. So, we love talking about things like this because we love learning from our own mistakes and also the mistakes that other people make when they're managing some of these patients. What are some of the biggest mistakes you see clinicians making when managing blepharitis or ocular surface disease, and what's some of the advice that you would give to residents and fellows?

Caroline Watson (23:30): I think what I see a lot of is them treating patients with steroids chronically. And obviously everyone feels better when they're using a steroid drop, doesn't matter what it is, they're going to feel better. But the problem is yes, you're temporizing the problem, but you're not addressing what's going on underneath. And so, patients will feel better for that six to eight to 12 weeks you have them on a steroid with a random taper and who knows, right? I mean, I've seen it all, but then you taper them off or you stop it and the problem comes right back. I also see them using weird oral and topical antibiotics. And so, I think that can sometimes be problematic if you don't know what you're actually treating, you're just kind of blanket treating what you think is going to work.

(24:39): And so that can be a little weird as well. And maybe treating with unnecessary procedures like punctal plugs, when you really need XDEMVY or you really need IPL. Yeah, okay, you may be able to help the tear lake a little bit, but overall, once those fall out, you're not going to have a happy patient. And I do use Lacrifill, so I'm not going to knock the plugs, but I like Lacrifill in conjunction while I'm kind of resetting everything just to give them a little relief and it's easy, quick, and it's covered by insurance for the most part. So, I wish everybody could be on the same page. I know that's hard, but definitively just simply start with the Demodex, start with the XDEMVY, start recognizing what rosacea truly looks like, start recognizing what NK looks like after chronic contact lens wear for 35 years. Those things are pretty straightforward because there are definitive ways to make those better.

(25:59): And I would just encourage everyone to do their due diligence, keep learning, keep going to meetings, listen to lectures, listen to Pupil Pod.

Sila Bal (26:09): Non-sponsored. No, but I totally agree with you. I also have patients, the steroids, I love steroids for my patients for the right patient, but the chronic steroid thing, and then you try to take them off of it and they're clutching their pearls because this steroid is everything to them. NSAIDs, topical NSAIDs as a cornea specialist, to see a patient that's been on a topical NSAID for years is really hard to deal with. So, I think we every year move the needle on ocular surface disease, on blepharitis management. We learn so much and we're able to offer different therapy. And I think the biggest thing is distinguished, does this patient have evaporative dry eye disease? Do they have aqueous deficiency? That will help you guide your management. Oftentimes they exist on a continuum, like you said, so sometimes we need to plug them, and we need to treat the Demodex, but we never put plugs in a hot eye ever, ever, ever.

(27:13): If the lids are hot, do not plug that punctum. We all know that now. But just making sure that you're really taking a look at the eyelids, the eyelid margin, the tear film, everything, and figuring out why this patient is symptomatic without just throwing a Band-aid on them. So, I think that is such great advice and a great segue to ending this episode.

Caroline Watson (27:38): I could talk to you all night.

Sila Bal (27:40): I could too. In fact, we have done that before. We fall asleep.

Caroline Watson (27:45): We love sleep.

Sila Bal (27:45): We do love sleep.

Caroline Watson (27:47): We do.

Sila Bal (27:48): Dr. Watson, thank you so much for joining us today.

Caroline Watson (27:52): Thank you. I'll talk to you later.

Sila Bal (27:53): And thank you to our listeners. Hope to see you next time on the Pupil Pod.