CORNEA/EXTERNAL DISEASE

A Comparative Study of Eyelid Cleaning Regimens in Chronic Blepharitis
James E. Key, MD

Purpose: Blepharitis, an intrinsic eyelid inflammation with crusting and irritation, presents a great problem for patients wearing contact lenses. An important part of blepharitis therapy is eyelid hygiene, including the use of either soap, dilute baby shampoo, or commercial lid scrubs. In this study, a comparison was made between these three cleaning regimens in a group of 25 patients, 80% of whom (20/25) wore contact lenses.

Methods: Patients used commercial eyelid scrub on right eyelids and a hypo-allergenic bar soap on left eyelids. Patient symptoms, slit lamp findings, and overall preferences were determined at the end of 4 months. A subgroup of 10 patients using lid scrub on right eyelids and dilute baby shampoo on left eyelids was followed for an additional 3 months.

Results: At the end of 4 months, 24% (6/25) of the patients noted no difference between soap and lid scrub, but 89% (17/19) of the others preferred the lid scrub. In the group using baby shampoo, 50% (5/10) noted no difference in 3 months, but 80% (4/5) of the remaining patients preferred the lid scrub.

Conclusions: All patients improved in slit lamp findings with all three regimens, and patient preference was overwhelmingly in favor of the lid scrub regimen for convenience and ease of use.

Introduction

The medical diagnosis of blepharitis includes eyelid inflammation and an associated symptom complex of irritation and crusting of the broad eyelid margin, which includes the eyelashes and associated apocrine and sebaceous glands. This inflammation is frustrating for the patient, particularly the contact lens wearer, and is difficult for the physician to manage. If left untreated, blepharitis can cause permanent structural damage in addition to ocular inflammation and discomfort. Blepharitis often requires medical treatment and next to dry eye syndrome is perhaps the major reason for contact lens failures.

A convenient classification of marginal blepharitis can be made based on terms of anatomical location. Anterior marginal blepharitis is either an infectious or noninfectious inflammation of the anterior eyelid margin that can lead to ocular surface disease. Posterior marginal blepharitis (posterior to the grey line of the lid) is a condition of the eyelid margin characterized by meibomian gland dysfunction that also can be inflammatory and/or infectious. Both anterior and posterior marginal blepharitis are associated with staphylococci infection, and further sub classification of these two principal conditions is based on groupings of observable signs.¹

Typical changes of chronic blepharitis are crusting and scaling of the eyelid margin often associated with angular blepharitis at the lateral canthus. Secondary conjunctivitis and marginal corneal infiltrates may be related to direct effects from bacterial exotoxins or to immunologic interactions with staphylococci cell wall antigens.² Clinical features include brittle crusting scales on the anterior eyelid margin that surround cilia, forming characteristic collarettes. The eyelid margins can be dry, thickened and hyperemic, and the eyelashes tend to mat together in tufts. Chronic inflammation can lead to eyelash loss, whitening, and trichiasis. Structural alterations of the eyelid margin include telangiectasia, hypertrophy, and notching or irregularity.³

One of the mainstays of therapy in controlling the symptoms of chronic blepharitis has been eyelid hygiene or cleaning. Eyelid hygiene includes use of warm compresses, expressing meibomian gland secretions, and cleaning the eyelid margins to remove keratinized cells and debris. The cleaning process is enhanced by the use of various soaps, particularly those without excessive perfume or lotion content, diluted baby shampoo, and/or commercial lid scrubs. All are widely prescribed by ophthalmologists, but there is no published study comparing the efficacy of cleaning regimens. The purpose of this study was to compare an eyelid cleaning regimen consisting of twice daily washing with a readily available high quality soap, Neutrogena, with a commercial eyelid scrub, OCuSOFT (OCuSOFT, Inc., Richmond, TX). A second part of the study was to take a subgroup of the patients and compare the commercial lid scrub with dilute baby shampoo.

Materials and methods

Twenty-six patients were enrolled in a 4-month study comparing the effect of eyelid hygiene with Neutrogena to an eyelid hygiene regimen using OCuSOFT. In the recruitment of patients, every effort was made to enroll contact lens wearing patients who had concomitant symptoms and signs of blepharitis. Of the 26 patients enrolled, seven were males and 19 were females. The average age of the patients was 37 years. In all of the patients, the use of ocular cosmetics such as mascara and eyeliner was minimized and the patients were instructed to keep their scalp, facial skin, and eyebrows clean, particularly of any moisturizing ointments used around the lids.

Nine of the patients were on medication prior to the study, largely use of antibacterial ointment in the evening. During the course of the study all medications were discontinued. Twenty of the patients were contact lens wearers and were allowed and encouraged to continue contact lens wear throughout the study. Eight of the patients wore soft contact lenses while 12 of the patients wore rigid gas permeable (RGP) contact lenses. Six of the patients did not wear contact lenses.

All patients enrolled in the study had an initial examination, and all were found to have normal ocular tear production and to be free of corneal involvement. This was done in an effort to better evaluate the symptomatic improvement. In the history prior to starting the study, the pre-study symptoms of burning and stinging, redness, itching, discharge and crusting were evaluated and given a ranking of I (minimal symptoms), II (moderate symptoms with discomfort) or III (severe discomfort). In addition to symptomatic evaluation, slit lamp examination was carried out and findings of hyperemia, corneal staining, structural alteration (notching), discharge, and crusting were also evaluated and ranked according to the same grading system.

The patients were then assigned to use the OCuSOFT lid scrub on the right eye in the morning and evening and to use Neutrogena bar soap on the left eye in the morning and evening. The patients were directed to close their eyes and apply the pre-moistened OCuSOFT pad on the right lids using repetitive horizontal motions for approximately 30 seconds to 1 minute. This was followed by a facial rinse with water. Neutrogena bar soap was then used to form a lather on the clean finger tips of the left hand and this was then applied to the left lids in a gentle oval scrubbing motion for up to 1 minute, followed by facial rinse. As previously stated, no other ocular medications were to be used other than re-wetting drops for the contact lens wearers as needed. The use of OCuSOFT pads is illustrated in Figure 1.

Figure 1 The use of OCuSOFT pads
  The patients were followed for 4 months with an initial evaluation at 6 weeks and at the end of the 4-month study. At each visit, rankings of patient symptomatology according to the severity grades were made and slit lamp findings were also noted for each area. Any additional findings were likewise noted. At the end of the study, the patients were given a questionnaire which asked them to rank the relative effectiveness and ease-of-use of the commercial lid scrub and the soap.

At the conclusion of the 4-month study, ten of the patients were asked to enroll for an additional 3 month study in which they would compare the use of OCuSOFT on the right eye with dilute Johnson's Baby Shampoo on the left eye. The baby shampoo was first diluted one-to-one with water in a "cup" in the palm of the hand. This was then mixed by rubbing with the fingertips and then applied in a gentle oval scrubbing motion to the closed left eyelids, followed by a fresh water rinse. Again, the same pre-study symptomatology and slit lamp findings were made, and the patients were again asked at the end of the study to fill out a questionnaire ranking the use of these two products.

Results

Of the 26 patients initially enrolled in the study, 25 (95%) completed the 4-month study. None of the contact lens patients had to discontinue contact lens wear throughout the 4-month period.

The findings of the pre-study evaluation of patient symptoms are noted in Table I. All patients enrolled in the study had at least two of the five symptoms elicited by history. The most common findings were crusting of the lids associated with a burning and stinging sensation. The pre-study slit lamp evaluation (Table II) showed all patients to have some degree of hyperemia; 80% (20/25) had oily discharge from the eyelid margin, with 84% (21/25) having the typical crusting and scaling of the anterior lid mar

gin. 1
TABLE I Pre-study symptoms
TABLE II Pre-study slit lamp findings

 The results at the end of the 4-month study are summarized in Table III and Table IV. The patients' complaints of symptoms were reduced dramatically with the use of either the OCuSOFT or the Neutrogena bar soap. Of the 25 patients who gave a history of red eyes prior to the study, only eight now thought their eyes were red, and none of them were judged to have Grade III symptomatology with significant involvement. The reduction in the symptoms of oily discharge as well as crusting were similarly dramatic, as 18 patients reported crusting of their lids prior to the cleaning regimens, and only six reporting lamp findings (Table IV) showed the same degree of improvement. Hyperemia was still the most noted finding at the slit lamp, but had been reduced from 100% of the patients to only 56% (14/25) and all of the Grade I variety. The one patient with inferior corneal staining had completely cleared; and even the two patients with lid alteration, which consisted of telangiectasia and minor notching, improved. Only two of the patients were found to have oily discharge at the end of the 4-month study, and only eight had any degree of crusting or scaling along the lid margin. Of the two patients still exhibiting an oily discharge, there was no difference between the OCuSOFT and the Neutrogena eye. Of the eight patients who still had crusting at the end of the study, five of the patients had crusting only on the left eye, including the one patient with Grade II level of crusting. This was the eye cleansed with the Neutrogena bar soap.

TABLE III Post-study symptoms
TABLE IV Post-study slit lamp findings

 Of the ten patients who were asked to continue using OCuSOFT Lid Scrubs on the right eye and dilute baby shampoo on the left eye, symptoms and slit lamp findings were minimal, as might be expected. All ten of the patients had Grade I hyperemia, and six of the patients had Grade I crusting when the comparison study began. At the end of this 3-month subgroup study, all of the OCuSOFT eyes were free of hyperemia and crusting, while the baby shampoo cleaned eyes still demonstrated Grade I hyperemia in three patients and Grade I crusting in two patients.

All patients were given an evaluation form at the end of the main 4-month study and at the end of the smaller 3-month study. In the evaluation form they were asked whether they felt their lids were cleaner using any of the regimens and whether the commercial lid scrub, bar soap, or baby shampoo was easier to use. They were then asked to state whether they would prefer using OCuSOFT Lid Scrub as opposed to Neutrogena soap and the OCuSOFT Lid Scrub versus Johnson's Baby Shampoo (diluted).

All patients felt that their lids were cleaner and their eyes more comfortable with the use of any of the three regimens. In the group using only OCuSOFT and Neutrogena, 24% (6/25) noted no difference between the two. Of the 19 patients who did note a difference, however, 89% (17/19) preferred the OCuSOFT to the use of soap. In the subgroup using OCuSOFT and dilute baby shampoo, 50% (5/10) noted no difference but of the five patients who did note a difference, 80% (4/5) preferred OCuSOFT to dilute shampoo (Table V).

TABLE V Patient preference

Discussion

Blepharitis, in its various forms, is a very common condition affecting all age groups. Successful treatment of blepharitis is usually measured in terms of relief of ocular discomfort and decreased signs of the disease. Contact lens wearers may be more prone to discomfort from blepharitis. Much of this group is made up of adolescents and young adults, a population already prone to excess oil production from apocrine and sebaceous glands. In addition, blepharitis can affect both the quality and the quantity of the tear film necessary for contact lens comfort, resulting in redness, irritation, foreign body sensation, and, ultimately, contact lens intolerance.

This study supports the thesis that eyelid margin cleansing is useful in controlling the symptoms of chronic blepharitis and in relieving the observable signs. Every patient in the study who used the commercial lid scrub or soap showed improvement in symptoms. Two patients prior to the study had Grade III symptomatology with significant ocular irritation, redness, discharge, and crusting. By the end of the first 6 week follow-up period and at the end of the study, there were no Grade III symptoms. Slit lamp findings prior to the beginning of the study showed nine patients with Grade II hyperemia and other patients with Grade II discharge, crusting, and lid margin inflammation. By the end of the study, the only Grade II slit lamp finding was one patient with crusting. If we break these findings down by which eye the patient reported was symptomatic or in which the observer saw slit lamp findings, nine of the 25 OCuSOFT eyes were symptom-free, while six of the 25 eyes treated with Neutrogena soap were symptom-free. At the slit lamp, 12 of the OCuSOFT eyes were completely normal, while just four of the 25 Neutrogena eyes had no observable signs of persistent blepharitis. For the ten patient subgroup that continued with OCuSOFT and compared it with baby shampoo in their other eye, all of the OCuSOFT patients were free of slit lamp findings, and eight of the ten were free of any symptoms at the end of 3 months. This would imply that 6 months of a consistent eyelid cleaning regimen with OCuSOFT would result in the great majority of patients being free of signs and symptoms of blepharitis.

Due to the small sample size and the fact that the major differences noted are all in the subjective findings, this study does not lend itself to statistical analysis. Indeed, most of the patient preference could be due to ease and convenience of OCuSOFT use, especially as compared with baby shampoo. One other factor that could affect results is cost. The daily use of OCuSOFT pads costs 25 cents/day, whereas the use of Johnson's Baby Shampoo or Neutrogena is calculated at 7 to 10 cents/day. In this study, the patients received samples of OCuSOFT on their return visits, although they still had to purchase a fair amount of their supply at retail cost.

There were no ocular complications from any of the products used. One patient did report that the OCuSOFT scrub made the skin around her eyelids too dry and that she would not continue with this product following the 4-month study. Two patients actually complained of stinging with the "no more tears" Johnson's Baby Shampoo, although there were no slit lamp findings. There were no complaints of discomfort with Neutrogena. The lack of complication is not surprising in that all three of these products are formulated to be specifically hypoallergenic and do not contain alcohol. Neutrogena and OCuSOFT contain no fragrances or dyes, although Johnson's Baby Shampoo contains both a yellow and orange dye and fragrances. It is interesting to speculate whether the presence of the dyes might have accounted for the mild irritation in two patients when this product was used around the eyes.

With eyelid cleansing alone with a commercial lid scrub preparation, this study demonstrates that almost half the patients (12/25) would be expected to be completely slit lamp free of observable signs of blepharitis at the end of a 4-month period. Although all three cleansing regimens did improve patient signs and symptoms, patient preference for the commercial lid scrub preparation was greater than for soap alone or dilute baby shampoo. The other important finding in this study as regards contact lens wearers is that no patient had to discontinue contact lens wear throughout the study due to their blepharitis. Even in those contact lens patients without blepharitis, it seems reasonable that regular eyelid scrubs would help to remove oils, debris and desquamated skin that might otherwise enter the tear film and contribute to contact lens discomfort and deposit buildup. Although no topical medications were used throughout this study, it could be that an eyelid cleansing regimen combined with a topical antibacterial medication, based upon the known sensitivity patterns of staphylococci, would be effective for symptom control in most patients. Appropriate initial choices of ointment would include mercuric oxide, erythromycin or bacitracin ointments, with other agents such as tobramycin considered for problematic cases.ª

In conclusion, eyelid margin cleansing with any of the three regimens involved is useful in controlling the signs and symptoms of chronic blepharitis. A commercial lid scrub, OCuSOFT, resulted in greater symptom resolution and patient satisfaction throughout the study.

References
¹ McCulley JP: Blepharoconjunctivitis. Int Ophthalmol Clin 1984;24(2):65.
² Ficker L, Ramakrishnan M, Seat D, et al: Role of cell-mediated immunity to staphylococci in blepharitis. Am J Ophthalmol 1991;111:473.
³ Wilhelmus KR: Inflammatory disorders of the eyelid margins and eyelashes. Ophthalmol Clin North Am 1992;5(2):187.
ª Hyndiuk RA, Burd EM, Hartz A: Efficacy and safety of mercuric oxide in the treatment of bacterial blepharitis. Antimicrobial Agents Chemother 1990;34:610.

From the Department of Ophthalmology, Baylor College of Medicine, Houston, TX.

Correspondence and reprint requests to: James E. Key, MD, 6624 Fannin, #2100, Houston, TX 77030. Accepted for publication September 22, 1995.