Blepharitis

By etiology

-simple

• Anterior marginal primary (inflammatory), - secondary (non-inflammatory)

-squamous - Posterior marginal primary (inflammatory), - secondary (non-inflammatory) -ulcerative

CLINICAL PROTOCOL FOR DIAGNOSIS AND TREATMENT

Clinical classification [1,2,4,5,6].

Stages By localization

Further patient management: patients are taught proper and regular treatment of the eyelid with antiseptic solutions, application of ointment, instillation of drops, eyelid massage. With regular treatment the prognosis is favorable, however the course of the disease is prolonged with frequent relapses. Prevention: preventive measures include hygiene of the eyelid margins, prevention of anterior segment infection, enhancement of general immunity. 3.5 Indicators of treatment effectiveness: disappearance of symptoms: redness and swelling of eyelid margins, itching, burning, foreign body sensation, tearing, scales and purulent crusts at the base of eyelashes, discharge from the conjunctival cavity. resolution of inflammatory changes of the eyelids. improvement of visual functions

ORGANIZATIONAL ASPECTS OF THE PROTOCOL: 6.1 List of protocol developers with qualification data: 1. Doshakanova Assel Baidauletovna – Candidate of Medical Sciences, ophthalmologist of the highest qualification category, senior lecturer of the postgraduate education department of JSC "Kazakh Research Institute of Eye Diseases". 2. Muravyeva Lyubov Anatolyevna – ophthalmologist of the highest qualification category, head of the consultative-rehabilitation department of JSC "Kazakh Research Institute of Eye Diseases". 3. Azhigalieva Mayra Narimanovna – Candidate of Medical Sciences, ophthalmologist of the highest qualification category, physician of the consultative-rehabilitation department of JSC "Kazakh Research Institute of Eye Diseases". 4. Doszhanova Bakyt Sagatovna – ophthalmologist of the highest qualification category, chief freelance ophthalmologist of Zhambyl region, deputy director of Zhambyl Regional Ophthalmological Center. 6.2 Indication of absence of conflict of interest: none. 6.3 Reviewers: Utelbayeva Zauresh Tursunovna – Doctor of Medical Sciences, Professor of the Department of Ophthalmology of JSC "National Medical University" 6.4 Indication of conditions for protocol revision: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with evidence level. 6.5 List of references used: 1) V.I. Morozov, A.A. Yakovlev, Pharmacotherapy of Eye Diseases. 1989 "Meditsina" 237p. 2) "Emergency Ophthalmology" Ed. E.A. Egorov 2004, "GEOTAR Media" 182p. 3) V.I. Morozov, A.A. Yakovlev "Pharmacotherapy of Eye Diseases", 2004 "Meditsina" 543p. 4) G.I. Dolzhich, R.R. Dolzhich Ophthalmology 2008, "Feniks" 286p. 5) L.K. Moshetova, A.P. Nesterov, E.A. Egorov "Clinical Recommendations" Ophthalmology 2006. "GEOTAR - Media" 238p. 6) Jack J. Kanski, Brad Bowling Atlas Reference Book. Ophthalmology 2009, "Med. lit." 177p. 7) Yu.S. Astakhov, G.V. Angelopulo, O.A. Dzhaliashvili reference manual, Eye Diseases 2001, "Spets. lit" 240p. 8) Smith R.E. Flowers C.W Chronic blepharitis a review, 1995 – vol 21, №3 – p 200207.

Approved

by the Joint Commission on Quality of Medical Services of the Ministry of Health

of the Republic of Kazakhstan dated February 28, 2019

Protocol No. 55

BLEPHARITIS

INTRODUCTORY PART

ICD-10 Code(s):

ICD-10

Code Name

H01

Other inflammation of eyelid

H01.0

Blepharitis

H01.1

Noninfectious dermatoses of eyelid

H01.8

Other specified inflammations of eyelid

H01.9

Inflammation of eyelid, unspecified

Date of protocol development/revision: 2014 (revised 2018)

Abbreviations used in the protocol:

BP – bacterial culture VOP – general practitioner GIT – gastrointestinal tract DM – diabetes mellitus UFO – ultraviolet irradiation

Protocol users: ophthalmologists, general practitioners.

Patient category: adults and children.

Evidence level scale:

A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic error, the results of which can be applied to the relevant population.

B High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of systematic error or RCT with low (+) risk of systematic error, the results of which can be applied to the relevant population.

C Cohort or case-control study or controlled study without randomization with low risk of systematic error (+).

The results of which can be applied to the relevant population or RCT with very low or low risk of systematic error (++ or +), the results of which cannot be directly applied to the relevant population.

D Case series description or uncontrolled study or expert opinion.

Classification

METHODS, APPROACHES AND DIAGNOSTIC PROCEDURES:

Complaints:

• itching of varying severity,
• redness of eyelid margins;
• burning, eyelid edema;
• scales at the base of eyelashes;
• discharge from the conjunctival cavity;
• foreign body sensation and tearing.

History:

• presence of diabetes mellitus and other endocrine pathology;
• presence of atopic, seborrheic dermatitis, acne rosacea, eczema, demodicosis;
• presence of concomitant GIT pathology;
• chronic recurrent inflammatory processes of the eyeball
• uncorrected or incorrectly corrected ametropia

Physical examination: skin of eyelid margins is edematous, hyperemic, possible presence of scales, purulent crusts at the base of eyelashes, foamy secretion and conjunctival edema.

Laboratory examinations: bacteriological examination of conjunctival cavity discharge for microflora with determination of antibiotic sensitivity, microscopy of eyelashes for demodicosis.

Instrumental studies: Visometry:

• decreased visual acuity

Biomicroscopy:

• assessment of tear film
• thickening and hyperemia of marginal eyelid edge
• presence of scales at the base of eyelashes in squamous blepharitis and crusts – in ulcerative blepharitis
• loss, abnormal growth of eyelashes
• edema and hyperemia of conjunctiva
• corneal epithelial defect

• Refractometry – determination of type of ametropia for subsequent correction.

• Indications for specialist consultations:
• endocrinologist – in presence of diabetes mellitus and other endocrine pathology,
• gastroenterologist – for GIT diseases,
• dermatologist – for skin diseases.

2.1 Diagnostic algorithm:

Diagnosis of blepharitis

Anti-inflammatory, medicamentous,

Differential diagnosis

Medicamentous anti-inflammatory, symptomatic therapy 2.2 Differential diagnosis and justification for additional studies: Diagnosis

Eyelid carcinoma

Justification for differential diagnosis

Examinations

resistance to ongoing treatment

1. cytological examination of eyelid

presence of long-standing unilateral blepharitis

Criteria for excluding diagnosis

1. Process is bilateral
2. Negative result of cytological examination.

TREATMENT TACTICS AT OUTPATIENT LEVEL:

Non-drug treatment:

• Regimen: III;

Drug therapy:

• treatment of eyelid margins with 1% alcohol solution of brilliant green.

• instillation into the conjunctival cavity of one of the antibiotic solutions

(0.25% chloramphenicol solution 1 drop 3 times a day, 0.3% tobramycin 1 drop 3 times a day, 0.3% gentamicin solution 1 drop 3 times a day, ciprofloxacin 0.3% solution 1 drop 3 times a day, levofloxacin 0.5% solution 1 drop 3 times a day, ofloxacin 1 drop 3 times a day).

• treatment of eyelid margins with ointments containing antiseptic agents (eye

ointment 2% with bibrocathol), corticosteroids, antibiotics and their combination (0.5%, 1% hydrocortisone eye ointment, 1% erythromycin eye ointment, tetracycline eye ointment, tobramycin eye ointment, ofloxacin eye ointment, dexamethasone+ tobramycin eye ointment,

dexamethasone+neomycin+polymyxin eye ointment – application to eyelid margins and placement behind lower eyelid 2 times a day).

• metronidazole tablets 0.25g 2 times a day for 10 days. [5, p.6]

Note: Corticosteroids are not used for demodicosis, as they reduce local immunity and increase mite numbers. When keratitis develops – corticosteroids are contraindicated.

List of essential medicines (with 100% probability of use) Drug group International nonproprietary name Method of administration Evidence level Antiseptic agent 1% alcohol solution of brilliant green Treatment of eyelid margins EL – D Antiseptic agent 2% eye ointment bibrocathol Treatment of eyelid margins EL – D Antimicrobial agent for topical use Chloramphenicol 0.25% solution eye drops Instillations into conjunctival cavity EL – C Antimicrobial agent for topical use Gentamicin 0.3% solution eye drops Instillations into conjunctival cavity EL – C Antimicrobial agent for topical use Tobramycin 0.3% solution eye drops Instillations into the conjunctival

sac

LE – C

Antimicrobial drug for topical use Ciprofloxacin 0.3% solution eye drops Instillations into the conjunctival sac Antimicrobial drug for topical use Levofloxacin 0.5% solution eye drops Instillations into the conjunctival sac Antimicrobial drug for topical use Ofloxacin eye drops Instillations into the conjunctival sac Glucocorticosteroids for topical use Hydrocortisone eye ointment, 0.5%, 1% Lubrication of eyelid margins

Note: The listed antimicrobial drugs may be used for blepharitis that has developed as a result of chronic conjunctivitis or is accompanied by such.

List of additional medications (less than 100% probability of use) Drug group International nonproprietary name of medication Route of administration Level of evidence Combined drugs for topical use dexamethasone + tobramycin eye ointment Lubrication of eyelid margins LE – C Combined drugs for topical use dexamethasone + neomycin + polymyxin eye ointment Lubrication of eyelid margins LE – C Antimicrobial drug for topical use Erythromycin 1% eye ointment Lubrication of eyelid margins LE – C Antimicrobial drug for topical use Tetracycline 1% eye ointment Lubrication of eyelid margins LE – C Antimicrobial drug for topical use Tobramycin eye ointment Lubrication of eyelid margins LE – C Antimicrobial drug for topical use Ofloxacin eye ointment Lubrication of eyelid margins LE – C Antimicrobial drug metronidazole Per os

Surgical intervention: none.

Diet: Table No. 1, 5, 9 - as indicated.

Moist compresses Correction of ametropia Other types of treatment:

• eyelid massage for meibomian gland dysfunction;

• physiotherapy (UHF therapy, magnetotherapy, electrophoresis with antibiotic and vitamin solutions, UV irradiation, darsonvalization);

• electrolysis of hair follicles for trichiasis (diathermocoagulation).

INDICATIONS FOR HOSPITALIZATION WITH INDICATION OF TYPE OF HOSPITALIZATION: none. 5. TREATMENT TACTICS AT INPATIENT LEVEL: none.