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Eyelash Disorders
Disorders of the eyelashes (cilia) and of the associated structures at the base of the eyelashes such as the eyelash follicles, glands of Zeis and skin of the lid margin, have implications with respect to contact lens wear. Practitioners need to be aware of the possible existence of such conditions in contact lens wearers because it may explain ocular discomfort during lens wear and, in many instances, will be a contraindication for lens wear until the condition is resolved.
Eyelashes typically project from the anterior rounded border of the lid margin in two or three rows. They lie just anterior to the line of Marx – a grey line that indicates the position of the mucocutaneous junction. The superior eyelashes are longer and more numerous than those of the lower lid. Because upper lashes normally curl up and lower lashes normally curl down, lashes do not become tangled on eyelid closure. Eyelashes are typically darker than other hairs of the body, except in such conditions as alopecia areata.
External hordeolum (stye)
An external hordeolum – commonly known as a ‘stye’ – presents as a discrete inflamed swelling of the anterior lid margin ( Fig. 8.1 ). It is extremely tender to the touch and may occur singly or as multiple small abscesses. A stye is an inflammation of the tissue lining the lash follicle and/or an associated gland of Zeis or gland of Moll. It is typically an acute staphylococcal infection and, as such, commonly presents in patients with staphylococcal blepharitis.
Styes have a typical time course of about 7 days. Sometimes, a stye will discharge spontaneously in an anterior direction. If a patient is in particular discomfort, resolution can be facilitated by removing the eyelash from the infected follicle and applying hot compresses to the affected area.
Contact lens wear may add to the discomfort of a stye because of the mechanical effect of the lens. In soft lens wearers, mechanical pressure against the lens between the stye and the globe may effectively grip the lens and result in excessive lens movement during blinking. With a rigid lens fitted inter-palpebrally, the lens may bump against the lid margin with each blink, causing considerable discomfort. For these reasons, patients may prefer to discontinue lens wear during the acute phase of the formation of a stye.
Blepharitis
Blepharitis is typically classified as being either anterior or posterior. The condition is sometimes called ‘marginal blepharitis’ because it is observed along the lid margins. Anterior blepharitis is directly related to infections of the base of the eyelashes and manifests in two forms – staphylococcal blepharitis and seborrheic blepharitis. The severity of blepharitis can be quantified with reference to the grading scale for this condition given in Appendix A .
Recent literature has used the terms ‘posterior blepharitis’ and ‘meibomian gland dysfunction’ (MGD) as if they were synonymous, but these terms are not interchangeable. Posterior blepharitis describes inflammatory conditions of the posterior lid margin, of which MGD is only one possible cause. In its earliest stages, MGD may not be associated with clinical signs characteristic of posterior blepharitis. At this stage, affected individuals may be symptomatic, but alternatively, they may be asymptomatic and the condition regarded as sub-clinical. As MGD progresses, symptoms develop, and lid margin signs, such as changes in meibum expressibility and quality and lid margin redness, may become more visible. At this point, an MGD-related posterior blepharitis is said to be present (see Chapter 7 ).
Kabatas et al. reported the prevalence of Demodex infestation to be 67% in patients with blepharitis versus 55% in a control group without blepharitis (p = 0.18).
Staphylococcal anterior blepharitis
This condition is caused by a chronic staphylococcal infection of the eyelash follicles and leads to secondary dermal and epidermal ulceration and tissue destruction. It is often observed in patients with atopic eczema and occurs more frequently in females and in younger patients.
Slit lamp examination of patients suffering from this condition reveals the presence of hyperaemia, telangiectasis and scaling of the anterior lid margins. The scales are brittle ( Fig. 8.2 ) and, when removed, will leave a small bleeding ulcer. The lashes may appear stuck together, and in severe cases, a yellow crust can form as a kind of sleeve that covers the base of the eyelash; these sleeves are called ‘cuffs’ or ‘collarettes’ ( Fig. 8.3 ).
In long-standing cases, there may be a loss of some eyelashes (madarosis), some eyelashes may turn white (poliosis), and the anterior lid margin may become scarred, notched, irregular or hypertrophic (tylosis).
Hypersensitivity to staphylococcal exotoxins may lead to secondary complications, such as low-grade papillary and bulbar conjunctivitis, toxic punctate epitheliopathy involving the inferior third of the cornea and marginal corneal infiltrates.
Patients suffering from staphylococcal anterior blepharitis may complain of burning, itching, foreign body sensations and mild photophobia. Associated tear film instability may also lead to symptoms of dryness. Symptoms are often worse in the morning.
The following management strategies may be employed:
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Antibiotic ointment – after removing crusts, antibiotic ointment is applied, with a clean finger, to the lid margins.
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Promote lid hygiene – crusts and toxic products can be removed by scrubbing the lids twice daily with a commercially available lid scrub. Alternatively, regular washing with a warm, moist face cloth and occasional rubbing with diluted baby shampoo should alleviate the condition.
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Steroids – weak topical steroids may be tried in more severe and protracted cases, especially if the strategies described previously fail.
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Artificial tears – will provide symptomatic relief if the blepharitis is compromising the integrity of the tear film.
The treatment can be tailed off, as appropriate, as the condition improves. However, staphylococcal anterior blepharitis is difficult to treat, and the pattern of recovery is characterised by periods of remission and exacerbation.
Seborrheic anterior blepharitis
This condition is caused by a disorder of the gland of Zeis and the gland of Moll, which connect with eyelash follicles. It is frequently associated with seborrheic dermatitis of the scalp, eyebrows, nasolabial folds, retroauricular areas and sternum. The symptoms are similar but less severe than for staphylococcal anterior blepharitis.
The anterior lid margin displays a shiny, waxy appearance with mild erythema and telangiectasis ( Fig. 8.4 ). Soft, yellow greasy scales are observed along the lid margin ( Fig. 8.5 ); unlike staphylococcal anterior blepharitis, these scales do not leave a bleeding ulcer when removed. The eyelashes may also become greasy and stuck together.
As with the staphylococcal form, secondary complications of seborrheic anterior blepharitis include mild papillary conjunctivitis and punctate epitheliopathy. The main form of treatment is lid hygiene and artificial tears.
Implications for contact lens wear
Contact lens wear is generally contraindicated during the acute phase of anterior blepharitis, especially if the cornea is compromised. If contact lenses are worn during mild staphylococcal anterior blepharitis, attention to lens cleaning is critical to prevent continued re-contamination of the eye. Faherty suggested that contact lens wearers be advised to be careful of cross-contamination occurring among eyes, lenses, lens solutions and/or lens cases and to use cosmetics properly and with care. Daily disposable contact lenses will minimise such problems of cross-contamination.
Keys conducted a 4-month study on 20 contact lens wearers and six non-lens-wearing patients suffering from blepharitis to test the efficacy of various treatment regimens. These regimens were:
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eyelid cleaning with hypoallergenic soap;
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lid scrubbing with dilute baby shampoo; and
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use of a commercial lid scrub.
It was concluded that all three regimens resulted in improvement and that about 85% of patients preferred to use the commercial lid scrub.
Parasite infestation of eyelashes
Infestation of the eyelashes by mites or lice can lead to signs and symptoms that closely resemble blepharitis. Clinicians must therefore be aware of this possibility and must be able to distinguish among the three species of parasite that most commonly infest human eyelashes and associated structures. This is especially important in contact lens practice as failure to identify parasitic eyelash infestation will almost certainly lead to patient drop-out.
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