Blepharitis Preferred Practice Pattern®

AMERICAN ACADEMY™ OF OPHTHALMOLOGY Protecting Sight. Empowering Lives.™ Blepharitis Preferred Practice Pattern® © 2018 by the American Academy of Ophthalmology Published by Elsevier Inc. https://doi.org/10.1016/j.ophtha.2018.10.019 ISSN 0161-6420/18 Secretary for Quality of Care Timothy W. Olsen, MD Academy Staff Ali Al-Rajhi, PhD, MPH Andre Ambrus, MLIS Rachel Lastra Flora C. Lum, MD Doris Mizuiri Medical Editor: Susan Garratt Approved by: Board of Trustees September 22, 2018 © 2018 American Academy of Ophthalmology® All rights reserved AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners. Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. Correspondence: Ali A. Al-Rajhi, PhD, MPH American Academy of Ophthalmology, P. O. Box 7424, San Francisco, CA 94120-7424. E-mail: . The Cornea/External Disease Preferred Practice Pattern® Panel members wrote the Blepharitis Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Guillermo Amescua, MD Esen K. Akpek, MD Marjan Farid, MD Francisco J. Garcia-Ferrer, MD Amy Lin, MD, Cornea Society Representative Michelle K. Rhee, MD Divya M. Varu, MD David C. Musch, PhD, MPH, Methodologist Steven P. Dunn, MD, Co-chair Francis S. Mah, MD, Co-chair The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2018. The document was edited in response to the discussion and comments. Preferred Practice Patterns Committee 2018 Robert S. Feder, MD, Chair Roy S. Chuck, MD, PhD Steven P. Dunn, MD Christina J. Flaxel, MD Francis S. Mah, MD Randall J. Olson, MD Bruce E. Prum, Jr., MD David K. Wallace, MD, MPH David C. Musch, PhD, MPH, Methodologist The Blepharitis PPP was then sent for review to additional internal and external groups and individuals in July 2018. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered. Members of the Cornea/External Disease Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document. In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-practice-patterns). A majority (70%) of the members of the Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 had no financial relationships to disclose. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Esen K. Akpek, MD: Allergan – Grant Support; Novartis Pharma AG – Consultant/Advisor Guillermo Amescua, MD: No financial relationships to disclose Steven P. Dunn, MD: No financial relationships to disclose Marjan Farid, MD: Allergan, Johnson & Johnson Vision, TearScience – Consultant/Advisor Francisco J. Garcia-Ferrer, MD: No financial relationships to disclose Amy Lin, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon, Allergan, NovaBay – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Michelle K. Rhee, MD: No financial relationships to disclose Divya M. Varu, MD: No financial relationships to disclose Preferred Practice Patterns Committee 2018 Robert S. Feder, MD: No financial relationships to disclose Roy S. Chuck, MD, PhD: Novartis Pharmaceuticals – Consultant/Advisor Steven P. Dunn, MD: No financial relationships to disclose Christina J. Flaxel, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon Laboratories, Inc., Allergan, NovaBay – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Randall J. Olson, MD: No financial relationships to disclose Bruce E. Prum, Jr., MD: No financial relationships to disclose David K. Wallace, MD, MPH: No financial relationships to disclose Secretary for Quality of Care Timothy W. Olsen, MD: No financial relationships to disclose Academy Staff Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose Andre Ambrus, MLIS: No financial relationships to disclose Susan Garratt: No financial relationships to disclose Rachel Lastra: No financial relationships to disclose Flora C. Lum, MD: No financial relationships to disclose Doris Mizuiri: No financial relationships to disclose The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2018 are available online at www.aao.org/ppp. OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P61METHODS AND KEY TO RATINGS P62HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P63INTRODUCTION P64Disease Definition P64Patient Population P64Clinical Objectives P64BACKGROUND P64Prevalence P66Risk Factors and Associated Conditions P66Natural History P69CARE PROCESS P70Patient Outcome Criteria P70Diagnosis P70History P70Examination P71Diagnostic Tests P73Management P75Detection P75Treatment P76Follow-up P81Provider and Setting P82Counseling and Referral P82Socioeconomic Considerations P82APPENDIX 1. QUALITY OF OPHTHALMIC CARE ORE CRITERIA P84APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES P86LITERATURE SEARCHES FOR THIS PPP P87RELATED ACADEMY MATERIALS P88REFERENCES P89 As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved US Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration. All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code. Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD) codes for the disease entities that this PPP covers. The intended users of the Blepharitis PPP are ophthalmologists. Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Quality, and the American College of Physicians.3GRADE Working Group Organizations that have endorsed or that are using GRADE.http://www.gradeworkinggroup.org/Date accessed: September 19, 2018Google Scholar ♦All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.♦To rate individual studies, a scale based on SIGN1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar is used. The definitions and levels of evidence to rate individual studies are as follows: Tabled 1I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of biasI+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of biasI-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of biasII++High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalII+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causalII-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causalIIINonanalytic studies (e.g., case reports, case series) Open table in a new tab ♦Recommendations for care are formed based on the body of the evidence. The body of evidence quality ratings are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Good qualityFurther research is very unlikely to change our confidence in the estimate of effectModerate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateInsufficient qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain Open table in a new tab ♦Key recommendations for care are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do notDiscretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced Open table in a new tab ♦The Highlighted Findings and Recommendations for Care section lists points determined by the PPP Panel to be of particular importance to vision and quality of life outcomes.♦All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics♦Literature searches to update the PPP were undertaken in February 2017 and June 2018 in PubMed and the Cochrane Library. Complete details of the literature searches are available at www.aao.org/ppp. In the management of ocular surface disease, it is helpful to distinguish blepharitis and meibomian gland dysfunction (MGD) from aqueous deficient dry eye. Worsening of symptoms in the morning is typical of blepharitis, whereas worsening of the symptoms later in the day are typical of aqueous deficient dry eye. Blepharitis is typically a chronic condition that cannot be permanently cured, and successful management is dependent on patient compliance with a treatment regimen. This should be explained to the affected patient. Topical antibiotic ointments with or without corticosteroids or oral antibiotics can be used effectively in the treatment of blepharitis. Although azithromycin is used as a treatment for blepharitis, it may be hazardous when used orally in patients with cardiovascular problems. Specifically, oral azithromycin may lead to abnormalities in the electrical activity of the heart, with the potential to create serious irregularities in heart rhythm. In patients with blepharitis who do not respond to therapy, the possibility of carcinoma or immune-mediated diseases should be considered, particularly if the blepharitis is associated with a loss of eyelashes and/or conjunctival cicatricial changes. Early diagnosis and appropriate treatment can prevent disfigurement and may be lifesaving. Blepharitis is a chronic ocular inflammation that involves the eyelid margin primarily and is a common cause of chronic ocular irritation. The patient population includes individuals of all ages who present with symptoms and signs suggestive of blepharitis, such as eyelid and ocular irritation and redness. ♦Establish the diagnosis of blepharitis, differentiating it from other causes of irritation and redness♦Identify the type of blepharitis♦Establish appropriate therapy♦Relieve discomfort and pain♦Prevent complications♦Educate and engage the patient in the management of this potentially chronic disease Blepharitis can be classified according to anatomic location: anterior blepharitis affects the eyelid skin, base of the eyelashes and the eyelash follicles, and posterior blepharitis affects the meibomian glands. Blepharitis has traditionally been clinically subcategorized as staphylococcal, seborrheic, meibomian gland dysfunction (MGD), or a combination thereof.4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar Staphylococcal and seborrheic blepharitis involve mainly the anterior eyelid and can each be referred to as anterior blepharitis. Meibomian gland dysfunction, as defined by the International Workshop on Meibomian Gland Dysfunction (www.tearfilm.org/mgdworkshop/index.html), is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease. Meibomian gland dysfunction is further subcategorized into hyposecretory, obstructive, and hypersecretory forms.5Nichols KK Foulks GN Bron AJ et al.The International Workshop on Meibomian Gland Dysfunction: executive summary.Invest Ophthalmol Vis Sci. 2011; 52: 1922-1929Crossref PubMed Scopus (627) Google Scholar This PPP covers the three clinical subcategories of blepharitis: staphylococcal, seborrheic, and MGD.6American Academy of Ophthalmology Basic and Clinical Science Course SubcommitteeBasic and Clinical Science Course. External Disease and Cornea: Section 8, 2017-2018. American Academy of Ophthalmology, San Francisco, CA2017: 71Google Scholar There is considerable overlap of symptoms in all types of blepharitis. Blepharitis frequently leads to ocular surface inflammation, including conjunctivitis, functional tear deficiency, and keratitis. Blepharitis may also exacerbate symptoms of coexisting ocular surface disease, including allergy and aqueous tear deficiency. The chronic nature of blepharitis, the uncertain etiology, and the frequent coexistence of ocular surface disease make blepharitis difficult to manage. Staphylococcal blepharitis is characterized by scaling, crusting, and erythema of the eyelid margin with collarette formation at the base of the cilia. Chronic inflammation may include acute exacerbations that lead to the development of ulcerative blepharitis. Loss of eyelashes and corneal involvement, including punctate epithelial erosions, marginal infiltrates, peripheral corneal and epithelial defects, and corneal neovascularization, may occur. Although coagulase-negative staphylococcus is isolated with great frequency from eyelids of both normal subjects and patients with blepharitis (in 89% to 100% of cases), Staphylococcus aureus is isolated with greater frequency from eyelids of patients with clinical diagnoses of staphylococcal blepharitis.4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar Both coagulase-negative staphylococcus and S. aureus are believed to play a role in the development of staphylococcal blepharitis, but the mechanisms of pathophysiology remain poorly understood. Toxin production has been reported to correlate with the presence of blepharoconjunctivitis;7Valenton MJ Okumoto M Toxin-producing strains of Staphylococcus epidermidis (albus). Isolates from patients with staphylococcic blepharoconjunctivitis.Arch Ophthalmol. 1973; 89: 186-189Crossref PubMed Scopus (28) Google Scholar however, other studies have found no association between toxin production of S. aureus isolates and the presence of clinical disease.8Seal D Ficker L Ramakrishnan M Wright P Role of staphylococcal toxin production in blepharitis.Ophthalmology. 1990; 97: 1684-1688Abstract Full Text PDF PubMed Scopus (25) Google Scholar Immunologic mechanisms have been documented. Enhanced cell-mediated immunity to S. aureus has been detected in 40% of patients with chronic blepharitis but not among normal subjects.9Ficker L Ramakrishnan M Seal D Wright P Role of cell-mediated immunity to staphylococci in blepharitis.Am J Ophthalmol. 1991; 111: 473-479Abstract Full Text PDF PubMed Scopus (30) Google Scholar Cell-mediated immunologic mechanisms have also been implicated in the development of keratitis associated with staphylococcal blepharitis.10Bowman RW Dougherty JM McCulley JP Chronic blepharitis and dry eyes.Int Ophthalmol Clin. 1987; 27: 27-35Crossref PubMed Scopus (39) Google Scholar Staphylococcal antigens themselves can initiate an inflammatory reaction by attaching to bacterial antigen-binding receptors that are present on the corneal epithelium.11Aderem A Ulevitch RJ Toll-like receptors in the induction of the innate immune response.Nature. 2000; 406: 782-787Crossref PubMed Scopus (2617) Google Scholar, 12Song PI Abraham TA Park Y et al.The expression of functional LPS receptor proteins CD14 and toll-like receptor 4 in human corneal cells.Invest Ophthalmol Vis Sci. 2001; 42: 2867-2877PubMed Google Scholar Patients with seborrheic blepharitis have greasy scaling of the anterior eyelid, and they frequently have seborrheic dermatitis of the eyebrows and scalp as well. Eyelid manifestations of MGD include prominent blood vessels crossing the mucocutaneous junction, frothy discharge along the eyelid margin, pouting or plugging of meibomian orifices, expression of meibomian secretions that range from turbid fluid to thick cheese-like material, thickening and scalloping of the eyelid margin, trichiasis, and chalazion. These changes can lead to eventual atrophy and fibrosis of the meibomian gland. Patients with MGD frequently are noted to have coexisting rosacea or seborrheic dermatitis.4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar, 13Lemp MA Mahmood MA Weiler HH Association of rosacea and keratoconjunctivitis sicca.Arch Ophthalmol. 1984; 102: 556-557Crossref PubMed Scopus (38) Google Scholar Alterations in the biochemical composition of meibomian gland secretions have been documented in patients with MGD blepharitis when compared with normal subjects.14McCulley JP Shine WE Meibomian secretions in chronic blepharitis.Adv Exp Med Biol. 1998; 438: 319-326Crossref PubMed Scopus (63) Google Scholar The result of MGD is decreased availability of normal meibum to the lid margin and tear film. This, in turn, may result in hyperosmolarity and instability of the tear film, increased bacterial growth on the lid margin, evaporative dry eye, and ocular surface inflammation and damage.15Schaumberg DA Nichols JJ Papas EB Tong L Uchino M Nichols KK The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD.Invest Ophthalmol Vis Sci. 2011; 52: 1994-2005Crossref PubMed Scopus (381) Google Scholar Although blepharitis is one of the most common ocular disorders, epidemiologic information on its incidence or prevalence within defined populations is lacking. One single-center study of 90 patients with chronic blepharitis noted that the mean age of patients was 50 years.15Schaumberg DA Nichols JJ Papas EB Tong L Uchino M Nichols KK The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD.Invest Ophthalmol Vis Sci. 2011; 52: 1994-2005Crossref PubMed Scopus (381) Google Scholar Compared with patients who have other forms of blepharitis, patients who have staphylococcal blepharitis were found to be relatively younger (42 years old) and most were female (80%).4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar, 16Yeotikar NS Zhu H Markoulli M Nichols KK Naduvilath T Papas EB Functional and morphologic changes of meibomian glands in an asymptomatic adult population.Invest Ophthalmol Vis Sci. 2016; 57: 3996-4007Crossref PubMed Scopus (45) Google Scholar In younger, active duty military personnel (mean age, 23.2 years), 5.3% were diagnosed with meibomian gland inflammation compared with 71.1% of older military veterans (mean age, 68.1 years).17Stanek S Meibomian gland status comparison between active duty personnel and U.S. veterans.Mil Med. 2000; 165: 591-593Crossref PubMed Scopus (21) Google Scholar A survey of a representative sample of US adults (n = 5000) revealed that typical symptoms associated with blepharitis are quite common and that younger people report more frequent symptoms than older individuals. A survey of ophthalmologists and optometrists reported that blepharitis was commonly seen in clinical practice in 37% and 47% of their patients, respectively. Meibomian gland dysfunction was considered to be the most common cause of evaporative dry eye disease.18Lemp MA Nichols KK Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment.Ocul Surf. 2009; 7: S1-S14Crossref PubMed Scopus (167) Google Scholar The prevalence of clinically diagnosed MGD varies widely in the published world literature,15Schaumberg DA Nichols JJ Papas EB Tong L Uchino M Nichols KK The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD.Invest Ophthalmol Vis Sci. 2011; 52: 1994-2005Crossref PubMed Scopus (381) Google Scholar with a suggestion that MGD is significantly more common among Asian populations than Caucasian populations. However, there is significant variation in how the disease was defined and in the age of the study groups.19Schein OD Munoz B Tielsch JM Bandeen-Roche K West S Prevalence of dry eye among the elderly.Am J Ophthalmol. 1997; 124: 723-728Abstract Full Text PDF PubMed Scopus (650) Google Scholar, 20Lin PY Tsai SY Cheng CY Liu JH Chou P Hsu WM Prevalence of dry eye among an elderly Chinese population in Taiwan: the Shihpai Eye Study.Ophthalmology. 2003; 110: 1096-1101Abstract Full Text Full Text PDF PubMed Scopus (467) Google Scholar, 21Uchino M Dogru M Yagi Y et al.The features of dry eye disease in a Japanese elderly population.Optom Vis Sci. 2006; 83: 797-802Crossref PubMed Scopus (148) Google Scholar, 22Jie Y Xu L Wu YY Jonas JB Prevalence of dry eye among adult Chinese in the Beijing Eye Study.Eye (Lond). 2009; 23: 688-693Crossref PubMed Scopus (254) Google Scholar, 23McCarty CA Bansal AK Livingston PM Stanislavsky YL Taylor HR The epidemiology of dry eye in Melbourne, Australia.Ophthalmology. 1998; 105: 1114-1119Abstract Full Text Full Text PDF PubMed Scopus (543) Google Scholar ♦Dry eyeDry eye has been reported to be present in 50% of patients with staphylococcal blepharitis.4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar Conversely, in a series of 66 patients with dry eye, 75% had staphylococcal conjunctivitis or blepharitis.24Baum J Clinical manifestations of dry eye states.Trans Ophthalmol Soc U K. 1985; 104: 415-423PubMed Google Scholar It is possible that a decrease in local lysozyme and immunoglobulin levels associated with tear deficiency may alter resistance to bacteria, predisposing to the development of staphylococcal blepharitis.10Bowman RW Dougherty JM McCulley JP Chronic blepharitis and dry eyes.Int Ophthalmol Clin. 1987; 27: 27-35Crossref PubMed Scopus (39) Google ScholarTwenty-five percent to 40% of patients with seborrheic blepharitis and MGD,4McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Scopus (244) Google Scholar and 37% to 52% of patients with ocular rosacea13Lemp MA Mahmood MA Weiler HH Association of rosacea and keratoconjunctivitis sicca.Arch Ophthalmol. 1984; 102: 556-557Crossref PubMed Scopus (38) Google Scholar also have aqueous tear deficiency. This may result from increased tear film evaporation due to a deficiency in the lipid component of the tears as well as reduced ocular surface sensation.25Stern ME Beuerman RW Fox RI Gao J Mircheff AK Pflugfelder SC The pathology of dry eye: the interaction between the ocular surface and lacrimal glands.Cornea. 1998; 17: 584-589Crossref PubMed Scopus (684) Google Scholar, 26Mathers WD Ocular evaporation in meibomian gland dysfunction and dry eye.Ophthalmology. 1993; 100: 347-351Abstract Full Text PDF PubMed Scopus (267) Google Scholar Low levels of tear film phospholipids have been found to be associated with the presence of dry eye in patients with chronic blepharitis.27Shine WE McCulley JP Keratoconjunctivitis sicca associated with meibomian secretion polar lipid abnormality.Arch Ophthalmol. 1998; 116: 849-852Crossref PubMed Scopus (110) Google Scholar♦Dermatologic con