An interview with Francis S. Mah, MD

Blepharitis, a chronic eye condition characterized by inflammation of the eyelids, as well as conjunctivitis, an inflammation or active infection of the conjunctiva, can affect treatment of retinal disease, whether it be an intravitreal injection or a vitrectomy. Retinal Physician spoke with cornea, cataract, and refractive surgery expert Francis S. Mah, MD, of Scripps Clinic in La Jolla, California, about considerations that retina specialists should take before treating patients for a retinal pathology who also have comorbid blepharitis and/or conjunctivitis.

Q: What are the major concerns of which retina specialists should be aware before injection or surgery when treating a patient who has blepharitis or conjunctivitis?

A: With active conjunctivitis or anterior blepharitis infection, we wouldn’t want to proceed with an elective surgery unless it was an absolute emergency or unless the patient was counseled appropriately as to the increased risk of postoperative infection as well as trying to minimize the risk of infection. The same goes for posterior blepharitis, which is a known risk factor for endophthalmitis in cataract surgery. For a patient who has active blepharitis or active infectious conjunctivitis, it makes common sense first to examine the eye, next to recognize the pathology, and then to counsel the patient. Especially for intravitreal injections and the majority of elective surgeries, it is probably better to defer unless the patient is really going to be negatively affected without the emergent procedure. Careful examination of each patient and recognition of the anterior segment signs are crucial. Then, management of the signs and symptoms in preparation for either an injection or surgery is critical. If we’re not looking for it, then we’re not going to catch it.

Q: What steps would a retina specialist take if they realize their patient has blepharitis or conjunctivitis? How long would they want to defer or delay a surgery and what should they have the patient do?

A: It’s different with each type of procedure, but in the setting of blepharitis for intravitreal injection and most elective retina surgeries, I would recommend doing warm compresses and lid scrubs twice a day for a couple weeks. I would advise 5 to 10 minutes of either a heated gel mask, making sure it’s not too hot. Then, I would advise cleaning the base of the eyelashes typically with the antiseptic, hypochlorous acid. There are various products that have hypochlorous acid, like Avenova’s eyelid cleansing spray Acuicyn (Sonoma Pharmaceuticals), Hypochlor (Ocusoft), and TheraTears (Akorn). I would also try to eliminate the most common normal flora that cause postoperative infections. Bacitracin is excellent against gram-positive bacteria such as Staphylococcus and Streptococcus, so I would choose that agent unless there was suspicion that the patient harbored gram-negative bacteria; in that case, I would utilize something that has gram-negative coverage like tobramycin, for example, Tobrex ointment (Alcon Laboratories Inc.). Erythromycin is used a lot, but erythromycin doesn’t have great coverage of gram-positive Staphylococcus sps., which are the most concerning bacteria. For the long term, an oral antibiotic like doxycycline can help. The reason to do this longer than a week is because there have been studies showing if only done for 1 week, the manipulation of the lids can actually increase normal flora in the periocular area.

For conjunctivitis, there are many excellent antibiotics that can be used if it’s bacterial, like besifloxacin (Besivance; Bausch + Lomb). The generic moxifloxacin is fairly readily available and is relatively inexpensive. If one is worried about fluoroquinolone resistance because the patient has been on a lot of fluoroquinolones in the past, one could use a polymyxin B and trimethoprim combination, or even Bleph 10 (sulfacetamide sodium 10%; Allergan) if the patient is not allergic to sulfonamides.

Q: When you’re assessing the patients, do you ever culture? Is it just a clinical diagnosis?

A: For conjunctivitis and blepharitis, it’s generally a clinical judgment. We rarely will do cultures for blepharitis or for conjunctivitis. Obviously, if one is in an academic institute or if there is access to an excellent microbiology laboratory, cultures can easily be done, but generally, the diagnosis is clinical. Because many of these procedures are elective, one can treat for several days and monitor response before doing a culture if resistant bacteria is suspected.

Q: For an emergent case for retinal detachment or a surgery that a retina surgeon wants to do quickly, are there any special considerations for trying to minimize complications?

A: There are a couple of things that you can do for a true emergency. First, I would copiously irrigate around the eye itself to get rid of any type of microbes. Second, meticulous prepping and draping of the patient, cleaning the base of the eyelashes, and using betadine 5% in the eye, especially in the conjunctival cul de sac and leaving in the eye for at least 5 minutes.

Q: Do you think there are specific cases in which retina surgeons have a surgery coming up and they should consult with cornea or anterior-segment colleagues about this?

A: Historically, it is interesting because the cornea specialists were the ones who researched, and managed infections including postsurgical cases. Then with the advent of vitrectomy and the Endophthalmitis Vitrectomy Study, postoperative management of infections transitioned over to the retina specialist. There might be some scenarios for which the anterior-segment or cornea specialist and the retinal specialist should work as a team, come up with an approach to help optimize the outcome. These might include a history of endophthalmitis, either in the contralateral eye or the eye that is going to be operated on; if the patient has a history of methicillin-resistant Staphylococcus aureus colonization; or if the management prescribed, whether it’s antibiotics for a presumed conjunctivitis or the regimen for blepharitis including topical antibiotics, does not seem to be effective.

Q: Can a retinal surgery exacerbate or even cause blepharitis or conjunctivitis?

A: Yes, ocular surface disease including dry eye and/or blepharitis can manifest or be exacerbated following any surgery including retinal procedures. Specifically during retinal surgery and injections, products used for the preparation of the procedure— such as dilating drops, numbing drops (proparcaine or tetracaine), and betadine (povidone-iodine) — can disturb the ocular surface. These can also disrupt the normal tear film and cause inflammation of the ocular surface. In addition, the eyelid speculum, the incisions, the trocars, and taking down the conjunctiva can lead to inflammation. We know now that inflammation is at the core of ocular surface disease, so even a routine, uncomplicated retina procedure or injection can definitely exacerbate dry eyes and/or blepharitis. We see it all the time with cataract surgery. The same can happen with retina surgery.

Another scenario in which the ocular surface can be challenged in a retina surgery is if there is edema in the cornea or keratitis due to some of the agents that were used prior to surgery such as glaucoma drops, topical steroids, and/or topical NSAIDs. A weak cornea, such as in patients who have diabetes where the epithelium is removed, can also be at risk of inflammation and therefore exacerbate dry eye and/or blepharitis.

We need to be aware of these situations that can play a role in exacerbating ocular surface diseases. If you identify the dry eye, blepharitis, or conjunctivitis before the surgery, you can counsel patients prior to surgery to optimize the ocular surface, as well as counsel the patient on possible outcomes such as conjunctival injection, foreign body sensation, or fluctuation in vision, which are all symptoms associated with ocular surface disease. That way, the patient has heard it and it’s documented in the chart. If there’s an exacerbation of the dry eye, the blepharitis, or the ocular surface disease after the routine procedure, you can remind patients that these symptoms are inherent to their eyes and were present prior to the procedure. Sometimes patients need reminding that this is not a new problem that was caused by the retina surgery; rather, it was something that they already had and it was exacerbated, so they need to go back to their therapy.

Q: Are there any other tips or points for retina specialists that you think are important to make?

A: I think this is a really important topic, and it’s something that we are definitely seeing a lot more of in treating the anterior segment, so obviously it’s also an important issue for retina specialists. Again, the number one consideration is recognition. Number two is that, even if a procedure goes well, the patients may experience symptoms such as a foreign body sensation; swollen, droopy lids; or conjunctival injection. Patients won’t be happy and they’re going to think that something went wrong even though the procedure was an uncomplicated one. Counseling patients is important for the patient outcome and experience. It starts with recognition and then just a couple of very simple strategies for management.