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Background: Demodex mites are microscopic parasites that live around hair follicles or sebaceous glands and may cause chronic blepharitis. The aim of this outcome analysis was to assess the efficacy and patient preferences with regard to the currently recommended treatment options., Methods: All patients with microscopic evidence for Demodex blepharitis were informed about the currently published treatments and instructed about daily lid hygiene. Additional topical treatment options included tea tree oil (TTO) 5%, a cleansing foam containing 0.02% TTO (Naviblef®), and metronidazole 2% ointment. Systemic treatment options included oral ivermectin 6 mg on day 1 and 14 and metronidazole 500 mg twice daily for 10 days. All patients were reviewed after 2 months for symptoms and for a mite count on 10 epilated lashes., Results: Ninety-four of 96 patients with Demodex blepharitis opted for an additional treatment. The mean mite count after 2 months of treatment were 13.3 with 5% TTO (n=6), 12.0 with 0.02% TTO (n=38), 9.4 with metronidazole ointment (n=5), 12.8 with ivermectin (n=27) and 22.0 with oral metronidazole (n=5)., Conclusion: While there are several published treatment options available, none of these options seem to be clearly effective in Demodex blepharitis., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To study the range of ocular manifestations in an Australian cohort of patients with pemphigus and bullous pemphigoid (BP), including a detailed assessment for dry eye syndrome (DES)., Methods: Twenty-two patients with pemphigus vulgaris, pemphigus foliaceus, and BP were referred for a detailed ophthalmology review between September 2011 and March 2012., Results: A total of 44 eyes of 22 patients with pemphigus vulgaris, pemphigus foliaceus, and BP were examined. Photophobia was the most common symptom reported. The most common ocular signs found in both groups were blepharitis (68.1%), conjunctival hyperemia (22.7%), and limbal broadening (18.2%). In our DES assessment, 92.9% of patients had a reduced Schirmer test score and an abnormal tear break-up time was recorded in 100% of patients. The ocular surface disease index score ranged from 0 to 47.2, with a median score of 10., Conclusions: The high occurrence of patient-reported ocular symptoms and clinical evidence of dry eye on Schirmer testing and break-up time demonstrate high prevalence of DES in our cohort of pemphigus and BP patients, which is a novel finding. Limbal broadening was another common finding not previously reported.

Aims: Demodex mites are implicated in several ocular surface diseases such as blepharitis, ocular rosacea and dry eye syndrome. Demodex eyelid infestation is classically diagnosed by analysing depilated eyelashes under the light microscope. The use of in vivo confocal microscopy (IVCM) could be an easy way to improve its diagnosis. The ability of IVCM to identify Demodex was evaluated and compared with the classic depilation method., Methods: Eight healthy subjects, 22 patients with dry eye syndrome without anterior blepharitis and 18 patients with anterior blepharitis were examined using lower eyelid IVCM (lash follicles and meibomian glands (MGs)). Twenty-five of the 48 subjects underwent both an IVCM examination and classic depilation to compare the two methods. Ex vivo Demodex obtained from lash depilation were also analysed using the confocal microscope., Results: IVCM found 100% of the mite infestations among patients with anterior blepharitis, 60% among dry eye patients without blepharitis and 12% in healthy subjects, whereas the depilation technique found 100%, 50% and 0%, respectively. Demodex brevis and Demodex larvae inside the lash follicles were better detected by IVCM. In symptomatic patients, the Demodex infestation was often associated with MG dysfunction, which was better characterised using IVCM in symptomatic patients (60% and 40% of meibomianitis and gland fibrosis, respectively)., Conclusions: IVCM is an efficient and reliable tool for the diagnosis of eyelid mite infestation and may also provide an evaluation of MGs., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Case Report: A 16-year-old female patient initially presented with bilateral swelling and redness of the eyelids already existing for the duration of two days. The symptoms had started after the patient dyed her eyelashes and eyebrows with henna., Therapy: Systemic antihistamine and glucocorticoid therapy led to no visible improvement. An intravenous antibiotic treatment was started which resolved the symptoms entirely., Conclusion: The diagnosis of an allergic contact dermatitis with a secondary bacterial infection was made.

Purpose: Floppy eyelid syndrome is a condition that is difficult to identify and diagnose and with no clear guidelines on its management. We propose a method of reliably grading this syndrome and have proposed a management algorithm based on the grading., Materials and Methods: Retrospective data collection of patients diagnosed with Floppy eyelid syndrome and treated under the care of a single oculoplastic surgeon over a 9 year period., Results: First, 102 patients were included and were classified into 3 groups. Grade 1 (F1) 7.5%, Grade 2 (F2) 36.5% and Grade 3 (F3) 56%. Only 12% of our cohort required surgery, and 92% of these patients demonstrated improvement in their symptoms., Discussion: Clinical grading of Floppy eyelid syndrome patients will help determine patient's management plan. In our experience, operating on both upper and lower eyelids at the same time where indicated helps to maintain the normal anatomical relationship and improve epiphora.

Purpose: To determine the incidence and density of Demodex species on the eyelashes of subjects with normal eyelids, anterior blepharitis (AB), meibomian-gland dysfunction (MGD), and mixed blepharitis (MB)., Materials and Methods: One hundred and fifty consecutive patients diagnosed with AB, MGD, and MB were recruited. An additional 50 individuals were recruited who were free of lid and margin disease to serve as a control group. All patients underwent a standard eye examination. Data on ocular symptomatology were gathered. Digital photography was performed of the lid margins. Lash sampling was performed by epilating the lashes and the lashes were checked for Demodex based on morphology using light microscopy. The total number of mites were tabulated for each eye. Comparison between the affected eyes and the control eyes was performed. Data were analyzed using the Chi-square test., Results: A total of 200 patients were included. Twenty percenth had AB, 40% had MGD, and 40% had MB. The incidence of Demodex infestation was 90% in cases of AB, 60% in MGD cases, and 90% in MB cases. The incidence of Demodex in control subjects was 18%., Conclusions: The incidence and density of Demodex infestation was highest in patients with AB and MB. Lid irritation and presence of cylindrical dandruff were indicative of a high-density infestation. These signs should alert the clinician to treat concomitant Demodex infestation.

Red eye and relapsing conjunctivitis-blepharitis are among the most common ocular disease in elderly patients. In these cases the search for causes is difficult and frustrating. We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea. In this patient the proper diagnosis was performed after 10 years of ocular disease, and repeated evaluations by general practitioners and clinical specialists, only after the appearance of facial signs of erythematotelangiectatic rosacea. Adequate therapy with oral doxycycline led to the improvement of the clinical picture that previously had shown a poor response to several topical treatments. The possibility of ocular rosacea should be considered in evaluating an elderly patient with persistent red eye and relapsing conjunctivitis-blepharitis. Making the proper diagnosis is crucial because ocular rosacea does not respond as expected to topical therapy and may lead to severe corneal involvement., (2014 BMJ Publishing Group Ltd.)

Objective: to evaluate the effectiveness of therapeutic eyelid hygiene in the treatment of chronic, or perennial, allergic blepharoconjunctivitis (ABC)., Material and Methods: A total of 30 patients with chronic ABC (11 men, 19 women aged 25-41 years; disease duration 2-4 years) were examined before and after a treatment course which included instillations of olopatodine hydrochloride instillations (1 mg/ml, 2 times daily) and hyaluronic acid (2 mg/ml, 3-4 times daily). Patients from the main group (18 patients, 36 eyes) additionally practiced therapeutic eyelid hygiene using Blepharoshampoo, Blepharolotion or Blepharosalfetka, and Blepharogel-1 (2 times daily). The control group was given only anti-allergic therapy and tear substitutes. Conventional ophthalmological examination, allergy testing, ABC signs and symptoms evaluation, Schirmer's 1 and Norn's tests, tear film break-up time evaluation, assessment of meibomian gland function, optical coherence tomography (OCT) for tear meniscus, xerosis index evaluation and lissamine green staining for lid wiper epitheliopathy, and anterior segment photography with further computer morphometry were performed in all patients., Results: Dry eye signs and symptoms, including combined lipid, water, and mucus tear deficiency, were found in all patients with chronic ABC. Patients from the main group demonstrated a significantly greater decrease of integral indices of subjective ocular discomfort, reduction of chronic ABC signs as well as more pronounced improvement of the meibomian gland function, appearance of the lid wiper region, tear film break-up time, results of the OCT-meniscometry, and xerosis index., Conclusion: Introduction of therapeutic eyelid hygiene to the complex treatment of chronic allergic blepharoconjunctivitis with the aim of resolving secondary dry eye symptoms enhances the effectiveness of the treatment.

Dermatophytes are rarely taken into account among the causes of blepharitis. In our report, we describe a 69-year-old man and a 40-year-old woman with chronic blepharitis for 10 years and 4 years respectively, in whom we examined the scales and pulled eyelashes on direct microscopy and isolated Microsporum audouinii and Trichophyton verrrucosum in the culture. We emphasise that dermatophytes may play a role in the etiopathogenesis of chronic blepharitis. In chronic, treatment resistance blepharitis fungal infections may be considered as possible cause., (© 2014 Blackwell Verlag GmbH.)

Objective: The diagnosis of Sjögren's syndrome (SS) in routine practice is largely a clinical one and requires a high index of suspicion by the treating physician. This great dependence on clinical judgment frequently leads to delayed diagnosis or misdiagnosis. Tear protein profiles have been proposed as simple and reliable biomarkers for the diagnosis of SS. Given that cathepsin S activity is increased in the lacrimal glands and tears of NOD mice (a murine model of SS), the aim of this study was to explore the clinical utility of using tear cathepsin S (CTSS) activity as a biomarker for SS., Methods: A method to measure CTSS activity in tears eluted from Schirmer's test strips was developed and validated. Schirmer's tests were performed and CTSS activity measurements were obtained in 278 female subjects, including 73 with SS, 79 with rheumatoid arthritis, 40 with systemic lupus erythematosus, 10 with blepharitis, 31 with nonspecific dry eye disease, and 12 with other autoimmune diseases, as well as 33 healthy control subjects., Results: The median tear CTSS activity in patients with SS was 4.1-fold higher than that in patients with other autoimmune diseases, 2.1-fold higher than that in patients with nonspecific dry eye disease, and 41.1-fold higher than that in healthy control subjects. Tear CTSS levels were equally elevated in patients with primary SS and those with secondary SS, independent of the Schirmer's test strip values or the levels of circulating anti-SSA or anti-SSB antibodies., Conclusion: Markedly high levels of tear CTSS activity are suggestive of SS. CTSS activity in tears can be measured in a simple, quick, economical, and noninvasive manner and may serve as a novel biomarker for autoimmune dacryoadenitis during the diagnostic evaluation for SS., (Copyright © 2014 by the American College of Rheumatology.)

A case of leishmaniasis with predominantly ocular signs in a cat living in Switzerland and it's treatment is reported. The cat was imported from Spain 4 years earlier and was initially presented with chronic uveitis. Laboratory test results were negative for feline immunodeficiency virus (FIV), feline infectious peritonitis (FIP), feline leukaemia virus (FeLV) and Toxoplasma gondii, as well as for Bartonella haenselae and Leishmania spp. Twenty-one months later the cat was presented again because of development of keratitis and granulomatous blepharitis. Blood cell count revealed severe Pancytopenia; Cytology of fine needle aspirates of granulomatous lesions on both upper eyelids and of a corneal smear revealed intracytoplasmatic microorganisms. A preliminary diagnosis of leishmaniasis was supported by positive polymerase chain reaction from bone marrow and eyelid samples for Leishmania infantum DNA and by a high serum antibody titer for Leishmania spp. Treatment with Allopurinol (10 mg/kg, BID) orally led to rapid improvement of ocular signs, general condition and blood cell count with complete remission of lid and corneal lesions within 2 months of treatment.

Background: The efficacy of topical ophthalmic corticosteroids depends upon small modifications in preparations, such as drug concentration.The aim of this study was to confirm that hydrocortisone acetate (HC-ac) ophthalmic ointments of 2.5% and 1% are more effective than a 0.5% eye ointment., Methods: In this randomized, double-blind, placebo-controlled, parallel-group clinical study, the change of signs and symptoms of acute inflammation of the ocular surface and adnexa was evaluated in 411 subjects., Results: Median time to clinically relevant response as estimated by 50% reduction in clinical signs and symptoms (CSS) total score over the entire trial was similar for subjects treated with HC-ac 2.5% (73.5 h) and for subjects treated with HC-ac 1.0% (67.7 h) and was considerably and significantly longer for subjects treated with HC-ac 0.5% (111.8 h) [p < 0.001 for both dosages]. All trial medications were safe and well tolerated., Conclusion: Hydrocortisone acetate 2.5% and Hydrocortisone acetate 1% eye ointments are efficacious and safe treatments for acute inflammations of the ocular surface or adnexa, and showed significantly better efficacy than a control group treated with Hydrocortisone acetate 0.5% therapy., Trial Registration: Current Controlled Trials ISRCTN15464650.

A new combined method for treatment of chronic blepharitis associated with dry eye syndrome is developed. A total of 25 patients were enrolled. The treatment implied the use of artificial tears, Restasis, and Blephasteam spectacle frame. The course included 20 procedures on daily basis. The monitoring period was 1 year. A pronounced anti-inflammatory, reparative, and moistening effect as well as stabilization of the precorneal film was achieved in short time. Owing to the combined approach, negative side effects (such as burning, conjunctival irritation, and fluctuating vision) were minimized. Repeated treatment courses maintained the positive therapeutic effect and prolongated the remission.

Physicians in various specialties-and dermatologists in particular-frequently encounter various forms of inflammation of the eyelids and of the anterior surface of the eye. Distinguishing the cause of itchy, painful, red, edematous eyelids is often difficult. Because the uppermost layer of the eyelids is part of the skin that wraps the entire body, almost every skin disease in the textbook can affect the periorbital area as well. In this contribution, we focused on the most common such disorders that require special consideration, as a result of their special appearance, their challenging diagnosis, or the nature of their treatment. We reviewed the key features of several common dermatides that affect the eyelids, such as atopic dermatitis, seborrheic dermatitis, allergic contact dermatitis, airborne contact dermatitis, rosacea, psoriasis, and others. We focused on the special clinical features, causes, and treatments specific to the delicate skin of the eyelids. Because structures of the eye itself (i.e., the conjunctiva, the cornea, the lens, and the retina) may be involved in some of the discussed periorbital skin diseases, we found it useful to add a brief summary of the eyelid complications of those diseases. We then briefly reviewed some acute sight-threatening and even life-threatening infections of the eyelids, although dermatologists are not likely to be the primary care physicians responsible for treating them., (© 2014 Elsevier Inc. All rights reserved.)

Purpose: To report an unusual case of Demodex folliculitis presenting as periocular vesiculopustular rash., Design: Case report., Results: A 68 year-old woman presented with a unilateral periocular rash that was initially treated by her primary ophthalmologist with topical steroids and antivirals. Slit-lamp examination revealed severe bilateral blepharitis, right greater than left, with waxy sleeves around the eyelashes. The diagnosis of Demodex infestation was considered. Treatment with daily lid scrub with polyhexamethylene biguanide (PHMB), 1,2-hexanediol and 1,2-octanediol (OCuSOFT PLUS) and erythromycin ointment twice a day resulted in complete resolution of the symptoms after 4 weeks., Conclusions: Ophthalmologists should be aware of Demodex and consider it in the differential diagnosis of periocular skin lesions.

Introduction: Phthiriasis palpebrarum is an ectoparasitosis in which Phthirus pubis infest the eyelashes. It is rare and it can easily be misdiagnosed as blepharitis. The purpose of this study is to describe seven cases of phthiriasis palpebrarum so as to discuss its mode of infestation, diagnosis and treatment., Patients and Methods: This is a study of all cases of phthiriasis palpebrarum reported in our laboratory. For each patient, an ophthalmic examination and parasitological examination of the eyelashes were performed., Results: There were five men and two women. Their ages ranged from 4 to 50years with an average of 21.57years. There were four children and three adults. The main symptom was itching of the eyelids. Clinical signs included reddish-brown crusts at the base of the eyelashes in all the cases and visible lice and nits in three cases. Biomicroscopic examination showed lice and nits anchored to the eyelashes in three cases. In the other two cases, the initial diagnosis was felt to be blepharitis. In all cases, the diagnosis of phthiriasis palpebrarum was confirmed by parasitological examination of eyelashes, which revealed the presence of adult and nit forms of Phthirus pubis. The number of adult lice ranged from 1 to 30. In all cases, treatment was based on mechanical removal of both the lice and nits. Outcomes were favorable without recurrence., Conclusion: In conclusion, phthiriasis palpebrarum can be easily diagnosed by close examination of the eyelashes and eyelid margins at the slit lamp and can be managed mechanically. Parasitological examination of the eyelashes can confirm the diagnosis., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: To describe a standardized technique for acquiring and viewing photographic images of eyelids, assess the reproducibility and validity of a grading protocol for signs of anterior blepharitis, and to explore whether the signs depend on the eyelid or the area of the eyelid assessed., Methods: Subjects with anterior blepharitis ranging from none to severe were examined by ophthalmologists at clinical sites. Digital images of the eyelids of subjects were acquired using a protocol that allowed for the calibration of color and luminance. Three ophthalmologists at a centralized reading center applied a novel protocol for grading features of anterior blepharitis from the digital images viewed on color-calibrated monitors. The agreement among graders was assessed using percent agreement and weighted kappa statistics (Kw), and the correlation of photographic and clinical gradings was assessed using Spearman correlation coefficients., Results: Agreement among graders was excellent (Kw > 0.80) on the number of eyelid margin vessels and was substantial (Kw between 0.61 and 0.80) for erythema, collarettes, number of engorged vessels, and number of lashes. Grading of the photographic images and the clinical assessments of erythema and lid debris were moderately correlated (r = 0.27-0.45). The grades for different features depended on whether the upper or lower eyelid, eyelid skin or lid margin, and central or lateral lid were assessed., Conclusions: The application of a protocol to obtain and display calibrated digital images of eyelids supports the standardized assessment of anterior blepharitis in clinical care and research studies.

Objective: To summarize the clinical characteristics and the therapy effect of blepharitis patients in clinic., Methods: Retrospective case series study.Four hundred and thirty-eight patients were diagnosed clinically as blepharitis in Beijing Tongren Hospital from Jan 2009 to July 2012. Analyzed the general states of health, case history, and the clinical manifestation, to summarize the clinical characteristics of blepharitis. The patients were clinically degree indexing and treated appropriately. After 1-2 courses of the treatment, the effect was analyzed.main outcome measures:manifestation of lid margin, corneal, conjunctiva, and the results of tear tests., Result: Four hundred and thirty-eight patients were recorded, from 3 to 84 years old, and the average was 40 ± 18 years old.435 (99.3%) cases were suffered with double eyes.159(26.3%) cases were males, and 279 (63.7%) cases were females. Children group had 41 cases (9.4%), which from 0 to 16 years old. Adult group (17-59 years) included 331 cases, which were 75.6% in the study. 66 cases were in aged group ( ≥ 60 years), being 15.0% in all cases.176 cases (40.2%) were on mild stage, 174 cases (39.7%) on middle stage, and 88 cases (20.1%) were on serious stage. Aged group were significantly more than children group (χ(2) = 34.575, P < 0.05).No significant difference between male and female (χ(2) = 32.877, P = 0.192). In 222 cases (50.7%) blepharitis patients complicated with correlation of keratoconjunctivitis lesions, respectively 8.5%, 75.3% and 86.4% in the mild, moderate, and severe patients. Adult group cases were significantly more than Children and aged group (χ(2) = 362.785, P < 0.05). Aged group were significantly more than Children group (χ(2) = 362.785, P < 0.05). 303 cases (69.2%)were with tear abnormal. The moderate and serious patients were more suffered with tear abnormal than mild patients (χ(2) = 64.438, P = 0.000). Patients were followed up for 1.5 to 27 months, mean 8 months. According to different extent of blepharitis, patients were given 1 courses of treatment.333 cases were clinical recovery, and the other cases were improved obviously., Conclusions: Blepharitis occurs mainly in adults.It always complicate with dry eye and keratoconjunctival lesions.It is needed pay attention to by Ophthalmologist. The diagnosis and grade is based on typical clinical symptoms. The treatment according different grades should focus on the correct handling of the palpebral margin.

Purpose: To determine the prevalence of signs and symptoms of ocular surface disease (OSD) in patients using topical intraocular pressure-lowering therapy., Methods: In this cross-sectional study, 40 patients were consecutively recruited from the glaucoma clinic of a public hospital located in Rio de Janeiro, Brazil. Eligible patients were 18 years of age or older, with primary open-angle glaucoma or ocular hypertension and on the same topical ocular therapy for at least 6 months. The following data were considered: sex, age, medication history and number of years on topical intraocular pressure-lowering therapy. All patients underwent an evaluation of the ocular surface which included: an interview using the Ocular Surface Disease Index® (OSDI®) questionnaire, break-up time, biomicroscopy, fluorescein corneal staining and rose Bengal ocular surface staining., Results: The mean OSDI® score was 24.6 ± 20.7. Most patients (67.5%) had an abnormal score on the OSDI® questionnaire. In 25% of patients, the score was consistent with mild symptoms, 12.5% with moderate symptoms and 30% with severe symptoms. Blepharitis and punctate keratitis were diagnosed in 42.5% and 20% of patients respectively. Tear film instability was observed in 75% of patients and ocular surface staining with rose Bengal in 35%. A positive statistically significant correlation (r=0.4; p=0.01) was found between OSDI® scores and the duration of topical intraocular pressure-lowering therapy., Conclusion: Patients with primary open-angle glaucoma or ocular hypertension on topical intraocular pressure-lowering therapy have high prevalence of OSD. Longer duration since diagnosis is significantly correlated with worsening of OSD symptoms.

Importance: The study establishes the importance of genetic background for the expression of Down syndrome phenotype., Objective: To define the ocular manifestations of Down syndrome in infants and children in Cairo, Egypt, a historically isolated region, and compare them with systemic features and with findings in other geographic groups., Design and Participants: We prospectively studied the ocular status and systemic features of 90 infants and children with Down syndrome and monitored all patients for 3 years. The complete ophthalmic examinations were performed along with ultrasonography, if media opacities were evident. Thyroid and cardiac status were assessed. An extensive literature search for comparison was performed., Setting: Outpatient clinical genetics department at the National Research Centre in Cairo, Egypt., Main Outcomes and Measures: Ocular and systemic manifestations of Down syndrome in infants and children in Cairo, and comparison of these features with patients with this anomaly from other geographic regions and ethnic populations., Results: Fifty-two infants or children (58%) had at least 1 abnormal ocular finding identified at the first visit. Significant refractive errors (in 37 [41%] patients) were the most common. Nasolacrimal duct obstruction, blepharoconjuctivitis, or conjunctivitis was found in 18 (20%), strabismus in 13 (14%), cataract in 5 (6%), nystagmus in 3 (3%), and optic nerve dysplasia in 2 (2%). Brushfield spots were not found. Additional ocular features developed over time. Thirty-six patients (40%) had congenital heart defects, and many (31 [86%]) had associated ocular disorders; a statistically significant correlation with myopia was established. Chromosomal translocations were high. The phenotype in Cairo was distinct., Conclusions and Relevance: More than half of infants and children with Down syndrome in Cairo had ophthalmic abnormalities; myopia was correlated with congenital heart defects. Comparison of the specific ocular features in our population with those in previous worldwide studies shows differences that may be related to overexpression or polymorphisms of key, modifying genes or other mutations in this historically isolated region along the Nile River. Down syndrome is more common in the highly consanguineous and multiparous Middle Eastern populations, and our Cairo findings underscore regional differences.

Purpose: Demodex folliculorum and Demodex brevis are ectoparasites with an astounding prevalence of 100% in patients aged 70 years and older. Every person in this age group is estimated to carry a colony of 1000 to 2000 mites. With such a high prevalence, little attention has been paid to the mite among eye care practitioners. We demonstrate a clinical sequence in a set of case reports to identify the mite. The clinical sequence includes a clinical history of blepharitis, dry eyes, and/or ocular allergy; slit lamp examination of cylindrical dandruff; and confirmation using light microscope evaluation of epilated lashes., Case Reports: Patient 1 was a 68-year-old woman who demonstrates associations with dry eyes and diabetes. Patient 2 was a 44-year-old man with uncommonly seen D. brevis present. Patient 3 was a 40-year-old woman with dry eyes and allergy, showing mite tails protruding from base of lashes. Patient 4 was a 60-year-old woman who demonstrates the association with rosacea. Patient 5 was a 53-year-old woman intermittently taking topical steroid and antibiotic combination medications, with an actual mite photographed on the surface., Conclusions: Following a clinical sequence helps identify Demodex, the underdiagnosed, undertreated, and underappreciated ocular surface disease.

Purpose: To examine the proportion of Demodex folliculorum and D. brevis in the eyelashes of healthy and immunocompromised patients., Methods: Eyelashes were taken from 95 patients at the Pomeranian Medical University, Clinic of Haematology, and from 1091 healthy controls., Results: Demodex folliculorum and D. brevis were found in 22.9% of controls and in 20% of immunocompromised patients. In neither the control group nor the immunocompromised patients did we observe a correlation between the proportion of symptoms of blepharitis and the presence of Demodex spp. - symptoms including burning sensations, loss of eyelashes, sensitivity to light, smoke and dust, dacryorrhea (excessive flow of tears), and foreign body eye sensation. A correlation between itching eyes and Demodex spp. infection was found only in the control group. A correlation between the proportion of cylindrical dandruff in eyelashes and the occurrence of Demodex spp was found in both the control group and immunocompromised patients., Conclusion: Proportions of D. folliculorum and D. brevis, and also symptoms of blepharitis were similar in the control group and immunocompromised patients. Immunosuppression did not seem to increase the rate of Demodex spp. infection.

The ubiquitous skin mite Demodex has been implicated as an instigator of anterior blepharitis. To date, overpopulation of the organism has been verified by cilia epilation (Coston or modified Coston method). This monograph describes an alternate technique to isolate Demodex organisms by eyelash rotation within the follicle. Via this method, without epilation, mites are made visible in follicles that may or may not display the cylindrical cuffing characteristic of demodicidosis.

We present a case of blepharitis with symptoms lasting two years in duration and refractory to a host of prior medical treatments, including antibiotics, corticosteroids, cyclosporine, and baby shampoo. We recognized the clinical presentation as pathogomonic for demodicosis caused by the parasitic mite, demodex folliculorum, confirmed with light microscopy, and treated appropriately with tea tree oil and hygiene measures--achieving full resolution of symptoms. We highlight the presentation, treatment, and underscore demodicosis as an important, under recognized cause of blepharitis.

Purpose: To describe the pathologic changes in punctal stenosis by reporting the histopathologic findings in a series of punctoplasty specimens., Methods: Observational retrospective chart review. Electronic health records of all patients having punctoplasty over a 2-year period at an academic oculoplastic practice were examined. All patients whose records included pathology reports were entered into a database., Results: Twenty-four patients, representing 30 eyes, had pathology records in the electronic health records. Patients were 75% women and had an average age of 65 (19-88) years. Associated conditions included blepharitis (71%), dry eye syndrome, or Meibomian gland dysfunction (63%). Histopathologic examination demonstrated chronic inflammation in 11 eyes (36.7%), fibrosis in 7 eyes (23.3%), chronic inflammation and fibrosis in 4 eyes (13.3%), squamous metaplasia in 3 eyes (10%), normal conjunctival mucosa in 3 eyes (10%), and Actinomyces israelii canaliculitis in 2 eyes (6.7%)., Conclusions: Nearly all histopathologic specimens revealed findings consistent with inflammation, fibrosis, or both. These findings provide evidence to support the hypothesis that the many etiologic causes of punctal stenosis are linked by a common pathophysiologic mechanism involving inflammation.

Objectives: Various ocular lesions are associated with hepatitis C virus (HCV). Few studies have focused on untreated patients. This study aims to describe ocular lesions in untreated HCV-infected patients without ophthalmic symptoms by means of a comprehensive ophthalmologic examination., Materials and Methods: Ninety-five consecutive naive HCV chronically infected patients and 54 controls (blood donors) were enrolled in a prospective, cross-sectional, single-center study. The following variables were analyzed: age, sex, HCV viral load and genotype, liver fibrosis, visual acuity, biomicroscopy of the anterior segment, lacrimal function (tear break-up time) and Schirmer's tests), posterior segment examination, and intraocular pressure., Results: HCV-infected patients presented an almost four times higher risk of lacrimal function involvement by tear break-up time [odds ratio (OR)=3.76; 95% confidence interval (CI) 1.75-8.04, P=0.001] and Schirmer's test (OR=4.17; 95% CI 1.83-9.50, P=0.001) than the controls. The chances of palpebral biomicroscopic lesions (blepharitis) were also higher (OR=3.21; 95% CI 1.49-6.94, P=0.003). Mean tonometry was higher in HCV patients (right eye 14.4±2.3 vs. 12.2±1.5, P<0.001 and left eye 14.5±2.3 vs. 12.0±1.4, P<0.001)., Conclusion: Naive HCV patients even with no ophthalmic complaints presented a greater prevalence of lacrimal function abnormalities and a higher frequency of blepharitis compared with the control group. As never formerly described, intraocular pressure in HCV patients was higher than that in controls.

Background: Aromatase inhibitors are frequently used as an adjuvant therapy in the treatment of breast cancer. We observed that several patients taking aromatase inhibitors presented with severe dry eye symptoms, and we investigated whether there is a relationship between aromatase inhibitors and dry eyes in these patients., Design: Retrospective chart review., Participants: Forty-one women., Methods: A computerized search of health records was performed to identify patients using anastrazole, letrozole and exemestane seen by the Cornea Service from August 2008 to March 2011. The results were compared with age-matched controls., Main Outcome Measures: Ocular surface changes among aromatase inhibitors users., Results: Of the 41 women, 39 were Caucasians. Thirty-nine patients had breast cancer (95%), one patient had ovarian cancer (2.5%) and one had an unknown primary cancer. Mean age was 68 ± 11.3 years (range 47-95). Most common presenting symptoms were blurred vision in 28 (68%) patients, irritation/foreign body sensation in 12 (29%) patients, redness in 9 (22%) patients, tearing in 6 (22%) patients and photosensitivity in 2 (5%) patients. Mean Schirmer's test measurement was 11 ± 5.8 mm (range 0.5-20 mm). Blepharitis was noted in 68 of 82 eyes (73%), decreased or poor tear function in 24 eyes (29%), conjunctival injection in 18 eyes (22%) and superficial punctate keratitis in 12 eyes (29%). Among an age-matched population (45-95 years), dry eye syndrome was found in only 9.5% of patients., Conclusions: Because the prevalence of ocular surface disease signs and symptoms appears to be higher in study group than control patients, aromatase inhibitors might be a contributing factor to the dry eye symptoms., (© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.)

Background: Ocular manifestations are frequent in patients with inflammatory bowel disease., Aim: To evaluate for the first time the value of ocular symptoms in predicting ophthalmologic inflammation in inflammatory bowel disease., Methods: All consecutive inflammatory bowel disease patients seen in the Department of Gastroenterology (Nancy, University Hospital, France) between April 2009 and July 2011 were interviewed for this cross-sectional study using a pre-established questionnaire. If the patient had at least one ocular symptom, he systematically underwent an ophthalmologic examination (visual acuity, Break-Up Time test, Schirmer Test, slit-lamp exam with fundus examination)., Results: This cross-sectional survey was completed by 305 patients: 169 were women (55.2%), 228 had Crohn's disease (74.5%). Ninety-eight patients (32%) reported at least one ocular symptom: ocular irritation (56.8%), red eye (40.5%), blurred vision (37.8%), progressive visual loss (34.4%), ocular pain (31.1%), myodesopsia (23.3%), eyelid secretion (12.2%), dry eye (9.5%), watering (6.8%), diplopia (5.4%), metamorphopsia (4%), and sudden visual loss (4%). Following ophthalmologic examination (n=74), 41.9% patients had evidence of dry eye (n=31), 14.9% blepharitis (n=11) and 1.4% scleritis (n=1). No uveitis was reported., Conclusion: Ocular symptoms are frequent in inflammatory bowel disease, but are non-specific and rarely associated with ocular inflammation. Systematic ocular symptoms assessment is of poor value for diagnosing ocular inflammation in inflammatory bowel disease., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Blepharitis due to Meibom gland dysfunction (MGD) is presumed to be one of the main reasons for dry eye symptoms which occur in up to 50% of contact lens users. Thus, MGD presumably plays an important role in dry eye in contact lens wearers. In the present prospective, randomized and double blind trial the efficacy of two established treatment options for MGD and blepharitis was evaluated in symptomatic contact lens wearers., Methods: In this prospective, randomized 2-centre trial 53 symptomatic contact lens wearers suffering from blepharitis were included. Patients were randomly selected for two treatment groups: group A performed lid margin hygiene using the commonly recommended mild baby shampoo (Bübchen Kinder Shampoo-extra augenmild, Bübchen Werk Ewald Hermes Pharmazeutische Fabrik GmbH, Soest, Germany) and group B performed lid margin hygiene using a phospholipid-liposome solution specially designed for lid hygiene (Blepha Cura, Optima, Moosburg/Wang, Germany), each for 4 weeks. Before as well as 4 weeks after initiation of this study the following tests were performed: standardized subjective assessment using the ocular surface disease index, non-invasive break-up time (NIBUT) and objective evaluation of lid-parallel conjunctival folds (LIPCOF) and further lid margin criteria by double blinded evaluation of slit lamp photographs., Results: Of the 53 symptomatic contact lens wearers suffering from blepharitis 21 (39,6%) were randomly selected for treatment group A and 32 (60.4%) for group B. In both treatment groups there was objective and subjective improvement of symptoms of dry eye in contact lens wearers. Interestingly, there was a significantly greater improvement, subjective as well as objective, in treatment group B which used the phospholipidliposome solution for lid margin hygiene compared to group A using baby shampoo., Conclusions: Although both therapies improved symptoms of dry eye due to blepharitis in symptomatic contact lens wearers, patients using phospholipid-liposomal solution for lid margin hygiene demonstrated a significantly greater clinical benefit from the therapy. Thus, clinical practice recommending just baby shampoo for lid margin hygiene should be re-considered, as phospholipid-liposomal solution for lid margin hygiene appears to yield greater and faster clinical benefits for symptomatic contact lens wearers suffering from dry eye symptoms.

Discoid lupus erythematosus is a common form of chronic cutaneous lupus erythematosus, an autoimmune inflammatory disease that affects most of the human organs, including the skin, kidneys, joints, heart and lungs. We describe a 45-year-old Caucasian woman with a 21-year history of eyelid redness and irritation. She had been treated with antibiotics, steroids and eyelid hygiene, a therapy that resulted to brief periods of relief of symptoms. In the last 12 months, her symptoms seemed to have exacerbated, despite the administration of a local therapy. Following biopsy, a diagnosis of discoid lupus erythematosus was confirmed and the patient was placed on a systemic therapy with hydroxychloroquine. The eyelid inflammation decreased but severe scarring of the marginal eyelids persisted, resulting in cicatricial ectropion., (© 2012 The Authors. Clinical and Experimental Optometry © 2012 Optometrists Association Australia.)

Purpose: To evaluate changes in symptoms, objective tests, and signs after medical treatment of subjects with evaporative-type dry eye disease (EDE) caused by Meibomian gland dysfunction (MGD), and to analyze correlations among symptoms, signs and test results in the worse eyes (W-eyes) of the subjects., Methods: Prospective clinical study of 21 symptomatic subjects with EDE caused by MGD. Subjects who were diagnosed with EDE in a first visit were treated for 6 weeks and re-evaluated in a second visit. The differences between initial and second visits were evaluated. Correlations among clinical symptoms, signs, and test results were performed using the data of the W-eyes. Variables evaluated included: dry eye symptoms, best corrected visual acuity (BCVA), contrast sensitivity, conjunctival hyperemia, phenol red thread test, tear break-up time (TBUT), tear meniscus height (TMH), corneal fluorescein and conjunctival rose Bengal staining, tear lysozyme concentration, Schirmer test, and lid margin assessment., Results: All items evaluated improved after treatment, but only conjunctival hyperemia and TMH improved significantly. TBUT and lid margin changes improved, but still remained abnormal. There were significant correlations among symptoms questionnaires and some clinical tests (TBUT, conjunctival hyperemia, TMH, and conjunctival rose Bengal staining)., Conclusion: Despite the instability of the tear film and lid margin alterations that continued after treatment, subjects with MGD improved symptomatically. The low degree of correlations among W-eye signs, symptoms, and tests reflects the independency of symptoms and signs in this complex pathology.

Purpose: To describe the clinical characteristics, treatment, and outcomes of herpes simplex virus (HSV) infections of the cornea and adnexae to raise awareness and to improve management of this important eye disease in children., Design: Retrospective case series., Participants: Fifty-three patients (57 eyes) 16 years of age or younger with HSV keratitis (HSK), HSV blepharoconjunctivitis (HBC), or both in an academic cornea practice., Methods: The following data were collected: age at disease onset, putative trigger factors, coexisting systemic diseases, duration of symptoms and diagnoses given before presentation, visual acuity, slit-lamp examination findings, corneal sensation, dose and duration of medications used, drug side effects, and disease recurrence., Main Outcome Measures: Presence of residual corneal scarring, visual acuity at the last visit, changes in corneal sensation, recurrence rate, and manifestations of HSK were assessed in patients receiving long-term prophylactic systemic acyclovir., Results: The median age at onset was 5 years. Mean follow-up was 3.6 years. Eighteen eyes had HBC only; 4 patients in this group had bilateral disease. Of 39 eyes with keratitis, 74% had stromal disease. Thirty percent of HSK cases were misdiagnosed before presentation. Seventy-nine percent of patients with keratitis had corneal scarring and 26% had vision of 20/40 or worse at the last visit. Eighty percent of patients had recurrent disease. Six of 16 patients (37%) receiving long-term oral acyclovir had recurrent HSV, at least one case of which followed a growth spurt that caused the baseline dosage of acyclovir to become subtherapeutic., Conclusions: In a large series, pediatric HSK had a high rate of misdiagnosis, stromal involvement, recurrence, and vision loss. Oral acyclovir is effective, but the dosage must be adjusted as the child grows., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the clinical course of 2 pediatric ocular rosacea cases with a significant delay until diagnosis., Methods: We report 2 interventional case reports. Case 1 is a 10-year-old boy with 2 years of recurrent bilateral blepharitis, repetition chalazion, conjunctival hyperemia, and corneal ulcers, without response to topical antibiotics or topical and systemic steroids. Case 2 is a 9-year-old girl with keratoconjunctivitis and repetition chalazion since she was 2 years old, without improvement after consulting several ophthalmologists and performing several treatments throughout those years., Results: Rapid response to systemic erythromycin with marked improvement of both cases within a few weeks., Conclusions: Ocular rosacea is frequently misdiagnosed, particularly in the pediatric population. To our knowledge, this report demonstrates a case with the longest history before diagnosis (7 years) and another case in which a conjunctival biopsy was performed.

A 70-year-old woman came to ophthalmology outpatient department with complaints of repeated episodes of itching, redness and watering in both eyes of 3 months duration. She was treated with antibiotics elsewhere but had no improvement. Slit lamp examination showed lice and nits anchored to the eyelashes. Light microscopic examination of the matted eye lashes and crusts further helped in identification of the ectoparasites as Phthirus pubis (Pubic louse or Crab louse) with typical morphology.

Background: The syndrome of childhood blepharokeratoconjunctivitis (BKC) is frequently underestimated. While prevalent and aggressive among Indo-Pakistani/Middle-Eastern populations, we observe a recalcitrant destructive phenotype in white children/adolescents that persists into early adulthood and may require systemic immunosuppression., Methods: A cohort of 10 white patients (20 eyes), median age 15.2 (range 6-27) years were identified among 62 patients with BKC attending a tertiary referral centre. Clinical features were graded and lid/conjunctiva swabs were performed, before instituting a hierarchical therapeutic protocol comprising lid hygiene, topical/systemic antibiotics, intensive topical glucocorticoids and systemic immunosuppression., Results: The median duration of symptoms prior to presentation was 4.3 (range 1.2-16.3) years, with 14 eyes (nine patients) demonstrating 360° peripheral corneal vascularisation associated with encroachment/involvement of the visual axis in 10 eyes (six patients). Corneal perforation(s) occurred in three eyes (two patients). Intensive topical glucocorticoids enabled disease control in 10 eyes (seven patients). In six eyes (three patients), persistent active disease necessitated systemic immunosuppression (azathioprine (2), mycophenolate mofetil (1), prednisolone (1)) achieving disease remission within three months with no adverse events reported., Conclusions: Suboptimal treatment of BKC in white children may permit a progressively destructive sight-threatening phenotype, which may last into adulthood and require immunosuppression. Appropriate aggressive steroid-based and steroid-sparing strategies are vital for disease remission.

About 30% of people suffer from allergic symptoms, and 40% to 80% of them have eye symptoms. Atopic conjunctivitis is divided into seasonal allergic conjunctivitis and perennial allergic conjunctivitis. The treatment of seasonal allergic conjunctivitis is simple: antihistamines, anti-inflammatory agents, or cromoglycate. Perennial allergic conjunctivitis needs longer therapy with mast cell stabilizers and sometimes local steroids. Atopic keratoconjunctivitis requires long-term treatment of the lid eczema and keratoconjunctivitis. Vernal keratoconjunctivitis mainly affects children and young people. It commonly calms down after puberty. It demands intensive therapy, often for many years, to avoid serious complicating corneal ulcers. Giant papillary conjunctivitis is a foreign body reaction in contact lens users or patients with sutures following ocular surgery. Nonallergic eosinophilic conjunctivitis affects mostly middle-aged and older women with eosinophilic conjunctivitis and dry eye. Contact allergic blepharoconjunctivitis is often caused by cosmetics and eye medication. Work-related ocular allergies should be considered as a cause of resistant ocular symptoms in workplaces.

Purpose: To describe and evaluate the severity of pediatric blepharokeratoconjunctivitis in Asia., Design: Retrospective case series., Methods: Clinical records of patients diagnosed with pediatric blepharokeratoconjunctivitis at a tertiary referral center in Singapore from 1991 through 2010 were reviewed. Patients were graded as having mild (corneal involvement without scarring), moderate (corneal scarring), or severe (corneal scarring with thinning or perforation) disease based on recorded clinical findings., Results: Fifty-one patients were diagnosed with pediatric blepharokeratoconjunctivitis. The mean age at presentation was 10.2 ± 3.6 years, most patients were female (80.4%), and the mean duration of follow-up was 58.9 ± 44.0 months. Chinese (56.9%) subjects made up most of the cases. Most subjects had moderate (56.9%), followed by severe (37.4%) and mild (5.9%), disease. Four patients (7.9%) had an associated dermatologic disease. All patients were treated with topical antibiotics, and 98% were treated with topical steroids. Nineteen (37.3%) patients received systemic antibiotic therapy, and 1 received systemic steroid therapy. Three patients required deep lamellar keratoplasty (2 tectonic and 1 optical), and 2 underwent cornea gluing alone; all 5 of them were Chinese. Patients graded as having severe disease were more likely to undergo surgical intervention (26.3%) than patients who were graded as having moderate (0%) and mild (0%) disease (P < .05). The main complication of treatment was raised intraocular pressure in 7 (13.7%) patients requiring medical therapy. Overall, best-corrected visual acuity improved by 0.10 logarithm of the minimal angle of resolution units (P < .001) after appropriate medical and surgical intervention., Conclusions: Pediatric blepharokeratoconjunctivitis patients in Asia seem to have a more severe clinical presentation and course. Early and adequate management can arrest the disease process and can minimize visual morbidity., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Even though air pollutants exposure is associated with changes in the ocular surface and tear film, its relationship to the clinical course of blepharitis, a common eyelid disease, had not yet been investigated. Our objective was to investigate the correlation between air pollution and acute manifestations of blepharitis., Method: We recorded all cases of changes in the eyelids and ocular surface, and rated clinical findings on a scale from zero (normal) to two (severe alterations). Daily values of carbon monoxide, particulate matter smaller than 10 μm in diameter and nitrogen dioxide concentrations and meteorological variables (temperature and relative humidity) in the vicinity of the medical service were obtained. Specific linear regression models for each outcome were constructed including pollutants as independent variables (single pollutant models). Temperature and humidity were included as confounding variables., Results: increases of 28.8 μg/m(3) in the concentration of particulate matter and 1.1 ppm in the concentration of CO were associated with increases in cases of blepharitis on the day of exposure (5 cases, 95% CI: 1-10 and 6 cases, 95% CI: 1-12, respectively)., Conclusion: Exposure to usual air pollutants concentrations present in large cities affects, in a consistent manner, the eyes of residents contributing to the increasing incidence of diseases of the eyelid margin., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Meibomian gland dysfunction is a common ocular disorder affecting from 39 to 50% of population. Despite that, so far a pathophysiology path of the disease remains unknown, moreover there is no distinct border between physiology and the disease. There has been no clear diagnostic criteria. The purpose of this review was to combine a current knowledge of Meibomian gland anatomy, Meibomian gland dysfunction epidemiology, as well as presenting current definition, nomenclature, classification and diagnostic criteria. The importance of diagnosis associated with conditions such as aqueous tear deficiency, seborrheic dermatitis, and rosacea is emphasized. The available treatment methods are discussed. Meibomian gland dysfunction, blepharitis, dry eye syndrome.

We report a case of periorificial dermatitis caused by suboptimal inhalation of budesonide for asthma. The initial skin lesions presented in the eye surroundings, leading to diagnostic difficulties and treatment of presumed chalazion and staphylococcal folliculitis. After several months, the patient developed perioral papules and pustules and was diagnosed with periorificial dermatitis. He was efficiently treated with topical metronidazole and oral erythromycin., (© 2011 Wiley Periodicals, Inc.)