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FLOTCH (leukonychia totalis-trichilemmal cysts-ciliary dystrophy syndrome) syndrome is a rare genetic cutaneous disorder primarily characterized by multiple recurrent trichilemmal pilar cysts and leukonychia. It may be associated with ciliary dystrophy, koilonychia, and/or less frequently renal calculi and pancreatitis inherited in an autosomal-dominant fashion. We report the case of a 25-year-old Black woman who presented with white-colored fingernails and enlarging cysts in multiple locations including the scalp, rib cage, and forearm and was diagnosed with suspected FLOTCH syndrome. Pilar cysts in unusual locations along with distinct nail changes should prompt clinicians to consider further investigation for conditions such as FLOTCH syndrome.

Purpose: To propose additional items for established dry eye disease (DED) instruments that cover blepharitis-specific signs and symptoms and to determine the association between the clinical findings and subjective complaints., Methods: Thirty-one patients with blepharitis and DED were prospectively included in the pretest period for selecting suitable questions. In the main phase of the study, the selected questions were then tested on 68 patients with blepharitis and DED and 20 controls without blepharitis or DED. Pearson's coefficient of correlation was calculated between the blepharitis-specific questions, tear break-up time (TBUT), the Schirmer test score, and the ocular surface disease index (OSDI) score; and the similarity between the blepharitis-specific questions, OSDI questions, and objective parameters for DED was assessed via hierarchical clustering. Furthermore, the discriminatory power of the blepharitis-specific questions was investigated with the receiver operating characteristic (ROC) curve., Results: The additional question about heavy eyelids revealed a significant correlation with the OSDI score (r = 0.45, p < 0.001) and Schirmer score (r =  - 0.32, p = 0.006). Cluster analysis demonstrated the similarity between the question about heavy eyelids and TBUT. In addition, the OSDI questionnaire had the highest discriminatory power in ROC analysis, and the OSDI score significantly correlated with the specific questions about eyelids sticking together (r = 0.47, p < 0.0001) and watery or teary eyes (r = 0.34, p = 0.003)., Conclusions: The blepharitis-specific additional questions were closely associated with objective parameters for DED. The question about heavy eyelids might be well suited for recording the symptoms of hyposecretory and hyperevaporative dry eye with blepharitis., (© 2023. The Author(s).)

Purpose: To evaluate the efficacy of azithromycin hydrate ophthalmic solution for the treatment of internal hordeolum and meibomitis with or without phlyctenular keratitis., Study Design: Retrospective study., Methods: Patients diagnosed with internal hordeolum or meibomitis were prescribed azithromycin hydrate ophthalmic solution twice daily for 2 days and then once daily for 12 days. Depending on the presence of meibomitis-related keratoconjunctivitis (MRKC), we further divided the patients with meibomitis into three subgroups: meibomitis alone (non-MRKC group), meibomitis with non-phlyctenular MRKC (non-phlyctenular group), and meibomitis with phlyctenular MRKC (phlyctenular group). Inflammatory findings (eyelid redness and conjunctival hyperemia) were scored before and after treatment. Some patients also underwent culture testing fluids discharged by the meibomian gland orifices., Results: Three patients (3 eyes) had internal hordeolum and 16 patients (16 eyes) had meibomitis. After treatment, the inflammatory findings disappeared in all eyes with internal hordeolum. Among the patients with meibomitis, three eyes were in the non-MRKC, six in the non-phlyctenular, and seven in the phlyctenular group. The inflammatory findings were significantly improved only in the phlyctenular group. Among seven eyes with positive culture results, Cutibacterium acnes was detected in five, and treatment improved the inflammatory findings in all of these eyes., Conclusion: Azithromycin hydrate ophthalmic solution is effective for the treatment of inflammatory meibomian gland diseases, including internal hordeolum and meibomitis. In particular, the agent is highly efficient in patients with phlyctenular MRKC., (© 2023. Japanese Ophthalmological Society.)

Chronic eyelid and ocular itch affect many patients seeking dermatologic or ophthalmologic care and have a high burden on patient quality of life. Clinicians should consider the broad range of possible diagnoses when approaching the patient with itch of the eyes or eyelids lasting more than 6 weeks. Allergic conjunctivitis and allergic contact dermatitis are the most common causes of chronic itch of the eyes and eyelids, respectively. Other diagnoses to consider include atopic dermatitis, xerosis, neurogenic itch, dry eye syndrome, seborrheic dermatitis, blepharitis, rosacea, lichen simplex chronicus, and papulosquamous disorders. If no organic cause can be elucidated, diagnoses of psychogenic pruritus or chronic pruritus of unknown origin may be considered. Herein, we discuss the possible etiologies of chronic eyelid and ocular itch inclusive of clinical presentation, diagnostic considerations, and current therapies., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To determine the efficacy and safety of eyelid exfoliation treatment in dry eye disease (DED), blepharitis, and contact lens (CL) discomfort patients., Methods: A systematic review that included only full-length randomized controlled studies, reporting the effects of eyelid exfoliation treatment in 2 databases, PubMed and Web of Science, was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The search period was between October 29, 2022 and December 6, 2022. The Cochrane risk of bias tool was used to analyze the quality of the studies selected., Results: A total of 7 studies were included in this systematic review. Eyelid exfoliation treatment influence on DED, blepharitis, and CL discomfort were analyzed in 6, 4, and 2 studies, respectively. Eyelid exfoliation treatment achieved a better improvement than control group interventions in all reported variables. The mean differences between both groups were as follows: Ocular Surface Disease Index score of -5.0 ± 0.9 points, tear breakup time of 0.43 ± 0.2 seconds, ocular surface staining of -1.4 ± 1.5 points, meibomian glands secretions of 1.2 ± 1.1 points, meibomian glands yielding liquid secretion of 0.6 ± 0.3 points, microorganism load of -3.2 ± 4.7 points, and Contact Lens Dry Eye Questionnaire-8 of -2.15 ± 0.1 points. Minimal discomfort (n = 13) and eyelid irritation (n = 2) were the main complications after an eyelid exfoliation treatment., Conclusions: Eyelid exfoliation is a safe and effective treatment that should be indicated for DED, blepharitis, and CL discomfort., (Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

The aim of the study was to find the relationship between the inflammatory process on the eyelids (blepharitis) and Helicobascter pylori infection. The data of numerous studies are analyzed, which give grounds to suggest a possible pathogenetic or mediated role of H. pylori infection in the development and course of inflammatory eye diseases. Fundamental in these studies are the release of harmful compounds in the exhaled air of patients with H. pylori, such as ammonia, hydrogen nitrate and hydrogen cyanide, the restoration of impression cytology after H. Pylori eradication, the presence of H. pylori in the lacrimal fluid. In this regard, the authors conclude that there are three main possible pathogenetic mechanisms for the association between H. Pylori infection and blepharitis: chronic inflammation, endothelial dysfunction, and oxidative stress.

Background: Ocular rosacea is a common skin condition leading to dry eye that is difficult to manage., Objectives: To estimate the efficacy and safety of a new intense pulsed light device, Thermaeye Plus, for meibomian gland dysfunction and blepharitis due to ocular rosacea., Materials & Methods: This prospective, longitudinal study included 74 eyes of 37 consecutive patients with ocular rosacea, with mean age of 45.6±11.7 years. Four consecutive sessions were undertaken, including14 flashes with 10 J/cm² on the periocular area and facial cheeks on Day 1, 14, 28, and 49. Clinical evaluation was based on: ocular surface disease index (OSDI) and symptom score questionnaires, quality of live and facial severity degree, non-invasive tear meniscus height, non-invasive tear break up time, corneal fluorescein staining and eyelid margin and meibomian gland assessment. Adverse effects on the eye and periocular area, and systemic complications were evaluated., Results: The OSDI questionnaire showed a decrease in symptoms, achieving normal values in 91.9% of patients. The symptom score showed amelioration, with the most significant changes relating to dryness, foreign body sensation, light sensitivity, and pain. Longitudinal analysis showed the most significant improvement between baseline at Day 1 and 49. All eyelid signs improved, most significantly for telangiectasia/vascularity and blepharitis, leading to a 78% clearance of facial rosacea and 81.1% reduction of flushing. In total, 100% of the patients reported an improvement in their quality of life after treatment and 94.6% a very significant improvement (p<0.001)., Conclusion: These results demonstrate that Thermaeye Plus is an effective and safe treatment for ocular rosacea.

Background: The main objective of the study was to determine the prevalence of diabetic retinopathy (DR), other diabetes-related ocular changes (e.g., cataracts, corneal ulceration), and non-diabetic ocular disease in Ghanaian children and adolescents. The second objective was to evaluate the relationship between these conditions and age at diagnosis, current age, diabetes mellitus (DM) duration, and participant's sex., Methods: A cross-sectional study, undertaken by a multidisciplinary team, included a cohort of children and adolescents (4-19 years) with DM recruited from selected health facilities in Ghana, from March 2016 to September 2019, after written informed consent or assent. The cohort will be followed up for 3 years to determine the natural course of the ocular changes, reported later. Participants were examined for all microvascular and macrovascular complications, non-diabetic ocular disease, anthropometric measurements, laboratory characteristics and quality of life issues. Full ocular examination was also undertaken. Statistical Package for Social Sciences (SPSS Version 25.0) was used for the data analysis. Continuous and categorical variables were presented as mean and standard deviation (SD), median (interquartile range) and as percentages (%), respectively. T-test and Mann-Whitney U test were used in establishing associations., Results: A total of 58 participants were recruited. DR was detected in only 1 out of 58 (1.7%) participants at baseline. Cataracts were the most common ocular finding, detected in 42 (72%) at baseline. Other anterior segment changes observed included blepharitis 46 (79.3%) and tear film instability 38 (65.5%). There was a significant positive association between duration of the DM and the risk of cataract ( p = 0.027). Participants' age at diagnosis was significantly associated with the presence of prominent corneal nerves ( p = 0.004)., Conclusions: DR was uncommon in this cohort of young persons with DM in Ghana. Cataracts, blepharitis and refractive errors were ocular changes commonly observed. All young persons with diabetes should undergo regular eye examination in all clinics where follow-up care is provided.

Purpose: To evaluate associations between Demodex and its symptoms and ocular surface parameters in individuals with dry eye (DE)., Methods: A cross-sectional study of 119 individuals with DE symptoms or signs, grouped by the presence of ocular demodicosis, was performed. All individuals filled out questionnaires and underwent an ocular surface examination. Demographics, comorbidities, symptoms profiles, and ocular surface parameters were compared between the 2 groups. Multivariable regression analyses were used to determine which factors were associated with DE symptoms. Receiver operating curves analyses were performed to evaluate relationships between Demodex quantity and specific clinical phenotypes., Results: Demodex was highly prevalent in our population (68.9%) with average counts of 4.2 ± 3.9. Individuals with and without Demodex had comparable demographics. Overall, symptoms profiles were similar between individuals with and without Demodex using the Dry Eye Questionnaire 5 and Ocular Surface Disease Index. Individuals with Demodex, however, were more likely to report itching (58.5% vs. 35.1%, P = 0.03), with increasing frequency in those with higher Demodex counts. Individuals with Demodex also had more severe eyelid abnormalities [cylindrical dandruff (CD) and lid vascularity] and a more unstable tear film but similar tear production and corneal staining when compared with individuals without Demodex. Neither Demodex nor ocular surface findings related to DE symptoms in multivariable analyses. Receiver operating curves analysis revealed Demodex counts ≥2 maximized sensitivity and specificity for both itching (64.7% and 59.0%, respectively) and CD (80.4% and 60.4%, respectively)., Conclusions: Demodex is highly prevalent in an older population with DE. Symptom of itching and CD were the findings most specific for Demodex., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To explore the tolerability of automated conjunctival hyperemia quantification in children with blepharokeratoconjunctivitis (BKC) and its agreement with clinical activity grading and to explore the Children's Health Utility 9D (CHU9D) as a measure of health-related quality of life in children with BKC., Methods: We enrolled 63 children, 31 with BKC and 32 without ocular surface inflammation, with a median [interquartile range (IQR)] age of 10.6 (7.2-13.9) years for BKC and 11.4 (9.5-13.8) years for healthy volunteers. Two masked observers graded the ocular surface images. The children indicated discomfort during imaging on a 5-point Likert scale. Using nonparametric tests, we explored the interobserver agreement and the agreement of automated redness index (RI) measurements of limbal and bulbar conjunctival hyperemia with clinician assessment. The children also completed the 9-item CHU9D., Results: The children tolerated imaging well: median (IQR) Likert value of 0 ("comfortable") (0-0) in healthy volunteers and 1 ("a little bit uncomfortable") (0-2) in mild/moderate BKC. In children with BKC, the median (IQR) bulbar RI was 1.3 (0.8-1.6) and the median limbal RI was 0.7 (0.3-1.1). In healthy volunteers, the median bulbar RI was 0.8 (0.55-1.1; P = 0.162) and the median limbal RI was 0.3 (0.2-0.4; P = 0.02). The agreement between RI and clinical grading was high. There was no significant difference between the mean CHU9D utility score between the 2 groups [0.89 (SD 0.08) vs. 0.92 (SD 0.07); P = 0.15]., Conclusions: Automated conjunctival hyperemia quantification is feasible in children with ocular surface inflammation and may prove useful for long-term monitoring and as an objective outcome measure in clinical trials.

Purpose: The presence of Demodex species can be associated with blepharitis. Their pathogenic potential in meibomian gland dysfunction is discussed herein. The purpose of this study was to determine the prevalence of Demodex mites in eyelashes of Austrian patients with ocular discomfort and to evaluate associated changes of the lid margins and meibomian glands., Design: This is a case-control study., Methods: Two hundred twenty-nine consecutive patients with ocular discomfort from an Austrian dry eye clinic were investigated for the presence of Demodex mites on sampled eyelashes. Associations of a mite infestation with individual dry eye and lid parameters were assessed. Lid margins were evaluated for scales, vascularization, Marx line, expressibility and quality of meibum, and drop-out of meibomian glands., Results: Demodex mites were identified in 40.2% of patients suffering from ocular discomfort (mean mite count 3.3 ± 2.9 per patient). Infestation with mites was associated with the presence of significantly more cylindrical scales (sleeves), a higher Marx line score, and a lower quality of meibum compared with mite-free patients. There were no significant associations with the expressibility and the drop-out of meibomian glands., Conclusion: The prevalence of Demodex mites in patients with ocular discomfort is high. The mean mite count per patient in this Austrian dry eye unit population is lower compared with previously published data from Asian regions. The infestation of the eyelids with Demodex species is associated with changes of the anterior and posterior lid margin, suggesting a pathogenic role in blepharitis and meibomian gland dysfunction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Blepharokeratoconjunctivitis secondary to ocular demodicosis in the pediatric population is often neglected and may result in a serious sight-threatening condition. In severe cases, it can lead to corneal perforation necessitating urgent corneal transplantation. However, the shortage and high cost of donor corneas is the foremost limitation of keratoplasty in developing countries. Small-incision lenticule extraction is an advanced flapless femtosecond laser refractive procedure in which an intrastromal corneal lenticule is detached and removed to correct myopia and myopic astigmatism. We herein describe a technique in which lenticules are used for the management of corneal perforation secondary to Demodex-induced blepharokeratoconjunctivitis. The lenticule was sutured over the site of the perforated cornea using 10-0 interrupted nylon sutures. The globe integrity was maintained with a good visual outcome. Thus, tectonic keratoplasty using small-incision lenticule extraction appears to be a safe, cost-effective, and reliable alternative method for the management of corneal perforation secondary to blepharokeratoconjunctivitis.

Purpose: To investigate the prevalence of ocular Demodex folliculorum (DF) in an Irish population. To validate a modified Ocular Surface Disease Index questionnaire and employ it to evaluate the relationship between dry eye symptoms and the presence of DF., Methods: One hundred and fifty-six subjects were enrolled in an epidemiological cross-sectional prevalence study. Each subject completed a novel questionnaire on ocular symptoms and was assessed for the presence of DF. Data was analysed to assess prevalence and to search for significant links between each symptom and DF., Results: An overall prevalence of 68% was found. Total mean number of DF found on microscopic examination was 3.83 mites per subject (range 0-25). The presence of symptoms was higher among individuals with DF (P = 0.04). Itch was found to be the symptom most significantly associated with the presence and number of DF (P = 0.025 and P = 0.035, respectively). The questionnaire showed good internal consistency (Cronbach's alpha; α > 0.7) and good reliability (Intra-class Correlation Co-efficient; ICC > 0.7). The sensitivity and specificity of a positive symptom result using the questionnaire were 70.8% and 46.9%, respectively., Conclusion: There is a strong association between the prevalence of DF and symptoms, in particular itchy eyes. However, not all patients with DF will be symptomatic. The newly developed questionnaire is a reliable instrument for measuring change in symptoms over a period of time and suitable for observing patient reported outcomes in interventional treatment studies.

Meibomian gland dysfunction (MGD) is one of the primary causes of evaporative dry eye. Stagnation of meibum induces an unstable tear film, thus resulting in shortened tear film breakup time and superficial punctate keratopathy (SPK) in the lower cornea and punctate staining of lower bulbar conjunctiva. MGD is sometimes accompanied with inflammation (termed "meibomitis") via the proliferation of bacteria in the meibomian gland and eyelash area. Meibomitis is strongly related to ocular surface inflammation such as corneal cellular infiltrates and neovascularization, SPK, and conjunctivitis. It is difficult to differentiate SPK caused by dry eye from that caused by meibomitis. When clinicians are unaware of the existence of meibomitis, and only aware of SPK on the cornea, they often try to treat SPK as it is caused by dry eye using dry eye-specific eyedrops or even using punctual plugs when conservative therapy is ineffective. However, even when intensive dry eye therapy is applied, it may be unsuccessful until SPK caused by meibomitis is recognized and treated with systemic antimicrobial agents. Hence, the tear secreting glands, including the meibomian glands, and the ocular surface should be clinically considered as one unit (i.e., the meibomian gland and ocular surface [MOS]) when considering the pathophysiology and treatment of ocular surface inflammatory diseases (i.e., corneal epithelial damage). Following this clinical pathway, a treatment focusing on meibomian gland inflammation may be a more reasonable approach for meibomitis-related or associated keratoconjunctivitis to more effectively treat this ocular surface disease.

Objective: Demodex acari is an obligate ectoparasite, and it is usually located in the human hair follicles, eyelash roots, and sebaceous glands. The aim of this study was to investigate the presence of Demodex infestation in chronic blepharitis cases that are resistant to therapy., Methods: Patients who were admitted at the Istanbul Medipol University School of Medicine Hospital with a diagnosis of chronic blepharitis were included. All cases received conventional therapy at least three times. Three or four eyelash samples from patients with blepharitis were collected and examined under light microscopy. For the diagnosis, the presence of one or more Demodex parasites at 10× and 40× magnification by a light microscope was considered as positive for infestation., Results: Overall, 153 cases were included in the study. Of the cases, 79 (51.6%) were males and 74 (48.4%) were females. The mean age was 43.1±9.7 years. The presence of D. acari in the follicles of the eyelashes in patients with chronic blepharitis was found in 69 (45.1%) cases., Conclusion: D. acari should be considered in patients with chronic blepharitis, especially in treatment-resistant cases. We believe that it would be useful to search for the parasite in patients with blepharitis prior to treatment on a routine basis.

A six-year-old male patient was admitted to our hospital due to itching and scalding crusts that persisted 10-15 days in both eyes. Upon biomicroscopic examination, 5-6 semi-translucent, yellowish brown living lice attached to the upper eyelashes and a large number of eggs were observed. Following application of pilocarpine hydrochloride (Pilomann 2%, Bausch-Lomb) and topical proparacaine hydrochloride (Alcaine 0.5%, Alcon), the paralyzed parasites and eggs were manually removed by pulling with forceps. The lice were identified as adult forms of pubic louse, Pthirus pubis, and its eggs. The patient was treated with pilocarpine hydrochloride, which was applied thrice a day combined with pure vaseline. One week later, no lice or eggs were seen on the eyelashes.

The purpose of this article is to analyze the outcomes of two surgical techniques to treat major trichiasis. A retrospective chart review of 67 patients (89 eyelids) with major trichiasis was performed who underwent surgical treatment using one of two techniques: intermarginal split lamella with graft (ISLG group) or lid lamella resection (LLR group). There were 30 lids in the ISLG group with mean patient age of 71.8 years and 63.3% were females. There were 59 lids in the LLR group with mean patient age of 72.5 years and 52.5% were female. The minimum postoperative follow up was six months. Statistical analysis included descriptive measures, Goodman association test for contrasts between and within multinomial populations and nonparametric Mann-Whitney test for comparison between groups. P < 0.05 was considered statistically significant. The underlying causes of trichiasis were blepharitis (37.07%), chronic meibomitis (21.3%), multiple causes (20.2%), ectropion (11.2%), actinic keratosis (6.7%), or prior ocular surgery (3.3%). Postoperatively, in the ISLG group, there were 20% lids with complete success, 50% underwent laser or electrolysis, 16.7% required further surgery, and 13.3% were unsuccessful. Postoperatively, in the LLR group, there were 47.5% eyelids with complete success, 46.7% underwent laser or electrolysis, 6.8% required further surgery, and 5.1% were unsuccessful. There was a higher statistical chance of complete success with LLR (P < 0.05). LLR is superior to ISLG surgery for the treatment of major trichiasis. There is a greater chance of success with LLR and it is technically simpler.

Purpose: To estimate the prevalence of external punctal stenosis (EPS) in the elderly population and investigate associated factors., Methods: A total of 278 patients ≥65 years of age were evaluated for evidence of EPS from January to July 2016. Associated systemic, ocular, demographic, and lifestyle factors were investigated. Multiple logistic regression analyses were applied to evaluate the factors related to having EPS. P values <0.05 were considered statistically significant., Results: The prevalence of EPS in this study population was 63.3%, with a mean age of 70.67 ± 7.85 (65-92 years). The ocular factor that was most commonly related to EPS was chronic blepharitis (48.9%). EPS was also associated with taking glaucoma medications (95% CI, 0.08-0.96, p=0.043), smoking history (95% CI, 0.13-0.84, p=0.021), ectropion (95% CI, 0.004-0.26, p=0.001), complaints of tearing (95% CI, 1.11-3.52, p=0.02), and outdoor occupational activity (95% CI, 3.42-9.97, p<0.05)., Conclusions: EPS is more common in elderly patients than in the general population. Outdoor occupational activity, taking antiglaucomatous medications, ectropion, and smoking are significantly associated with EPS. In addition, surgical treatment decisions should be made after complete evaluation and interviewing the patients.

Purpose: To describe a pragmatic approach to the medical management of blepharokeratoconjunctivitis in children, based on published evidence and clinical experience., Methods: The authors used the Delphi consensus method to explore the preferred management patterns of four senior clinicians at one institution to reach agreement on indications and dosage schedules for commonly used treatments. Four iterations were created, with electronic questionnaires distributed via an online survey platform. Initial questions were based on recent systematic reviews and clinical experience. After each round, a facilitator summarized the responses and fed these back to the expert participants, together with an invitation to complete the next round of questions., Results: Typical and specific eyelid, corneal, and conjunctival disease features influenced management decisions, and treatments were targeted toward specific findings in these tissues rather than to overall disease severity. Active keratitis was considered the main indication for high potency steroids, systemic antibiotics, and possibly systemic immunomodulators. Other indications for systemic antibiotics were chronic active blepharitis and recurrent troublesome chalazia. Oral antibiotics were used for their anti-inflammatory and antimicrobial properties. There was little agreement on the role of dietary modification, topical lubricants, and preference for oral or topical antibiotics., Conclusions: Detailed clinical assessment of eyelids and ocular surface allows targeted treatment. Research is needed to clarify disease mechanisms and to optimize treatment strategies. [J Pediatr Ophthalmol Strabismus. 2017;54(3):156-162.]., (Copyright 2017, SLACK Incorporated.)

Demodecidosis is an ectoparasitosis of pilosebaceous unit caused by demodex mites. The disease may be a primary skin disease or a secondary disease to inflammatory dermatoses such as folliculitis and rosacea. Demodex spp. blepharitis is an infectious ocular disease that is common but always neglected. These mites contain lipase enzymes that help carry bacteria on the surface. The infestation of Demodex spp. has increasingly become a public health concern. A 29-year-old male patient was admitted to our dermatology clinic with a complaint of papules and pustules on his face, which started 4 years ago. A standardized skin biopsy specimen was evaluated in our microbiology laboratory, and we detected Demodex folliculorum mites on his face (3+). There was pruritus of his eyes. A total of four eyelashes were epilated and were then examined under a light microscope for the presence of Demodex infestation. In this study, we discussed the association between acne rocacea, blepharitis, and demodex mites.

Background: Pyodermatitis-pyostomatitis vegetans (PDPSV) is a rare inflammatory disorder of the skin and oral mucosa that is commonly associated with inflammatory bowel disease (IBD). Ocular involvement is uncommon., Objective: Given the association with IBD, it is important for dermatologists to be aware of the varying manifestations of PDPSV., Methods: A biopsy was performed for diagnosis confirmation, and the literature was reviewed for similar cases., Observations: Our 48-year-old PDPSV patient presented with rare ocular findings. There have been 8 PDPSV reports of ocular involvement. Only 3 of those patients developed blepharitis and/or conjunctival disease. None showed simultaneous involvement of sites at disease onset like our patient., Results: Our patient's concomitant presentation at onset of multiple mucocutaneous sites with blepharitis and conjunctivitis is unique., Conclusions: We propose the term pyoblepharitis vegetans (PBV) to describe vegetating lesions of the eyelids. The diagnosis of PDPSPBV should be considered with presentation of these signs., (© The Author(s) 2015.)

Objective: To summarize the clinical characteristics, diagnosis, and treatment of blepharokeratoconjunctivitis (BKC)., Methods: Retrospective analysis. One hundred and seventy-two patients were diagnosed as BKC between January 2012 and December 2014 at Beijing Tongren Hospital. The clinical characteristics, the degrees of blepharitis and BKC, and the therapeutic effect were evaluated., Results: The patients were aged from 2 to 78 years (mean, 27±18 years). Forty-nine patients (28.5%) were males, and 123 patients (71.5%) were females. One hundred and five patients had photograph records of lid margin, cornea, and conjunctiva. BKC was unilateral in 28 (26.7%) of them, and bilateral in 68 (64.8%) with similar degrees and in 9 (8.6%) with different degrees. The disease was mild in 39 patients (40.6%), moderate in 24 patients (25.0%), and severe in 33 patients (34.4%). There was no significant difference in the degree of BKC between males and females (χ(2)=1.022, P=0.600). A total of 1 875 patients were diagnosed as blepharitis during the same period, and 172 patients (9.2%) were complicated by BKC. Female patients with blepharitis were more susceptible to BKC (χ(2)=8.355, P<0.05). Among the children patients with blepharitis, the incidence of BKC was significantly higher than that in the other groups (χ(2)=224.566, P< 0.05), but in the degree of BKC, there was no significant difference among groups. Typical clinical findings consisted of punctuate epithelial and subepithelial haze, stromal infiltrates, corneal ulcer, corneal scar, and corneal pannus. The patients were followed up for 1 to 80 months (mean, 7 months). According to the different degrees of BKC, the patients were given treatment for 1 month. Sixty-nine patients (71.9%) had clinical recovery, and the other cases were improved obviously. Nine patients (15 eyes) had recurred BKC during the follow-up period, and the recurrence rate was 9.2%., Conclusions: BKC is not uncommon in patients suffering blepharitis, with a variety of clinical characteristics. Female and children patients with blepharitis are more susceptible to BKC. It is vital to perform standardized diagnosis and treatment for improvement of therapeutic effect.

Background: Necrotising soft tissue infection (NSTI) is an infection of the subcutaneous tissues and often follows a fulminant course if not recognised in time., Case Description: A 78-year-old man was brought to our emergency department in septic shock. Physical examination revealed an erythematous and painful swelling of the right eyelids and to a lesser extent of the right hand. The infection progressed at both sites, and suspicion of NSTI arose. An emergency surgical debridement was performed. Pathological examination of the excised tissue confirmed the presence of a necrotising infection of the fascia consistent with NSTI at both sites., Conclusion: This case history describes a, not previously described, 'double' presentation of NSTI. In a patient with misunderstood sepsis in combination with a soft tissue infection, it is important to consult a surgeon immediately. This case report emphasises the need for a multidisciplinary approach when treating patients with these clinical pictures., Conflict of Interest and Financial Support: NONE DECLARED.

Aims: To elucidate if topically applied atorvastatin safely decreases corneal fluorescein staining in dry eyes associated with blepharitis., Methods: Ten dry eye and blepharitis (DEB) patients were enroled in a prospective pilot study. All patients were treated with topical atorvastatin (50 μM) 8 times a day for 4 weeks and allowed to continue with their existing dry eye treatment. The patients were examined weekly for 4 weeks. The primary outcome measure was corneal fluorescein staining. Secondary outcome measures were tear film break-up time (BUT), Schirmer I testing, blepharitis score and bulbar conjunctival injection. The subjective efficacy was evaluated with global symptom and facial analogue scores., Results: An improvement in corneal fluorescein staining in the treated eye by >1 point from baseline to completion of the trial at week 4 was found in 9 of 10 patients (p < 0.01). Topical atorvastatin significantly improved the tear film BUT (p < 0.01), blepharitis score (p < 0.05) and bulbar conjunctival injection (p < 0.05). The global symptom score and facial analogue score also improved (p < 0.05). There were no side effects., Conclusion: Topical atorvastatin is a potential therapy for DEB patients. Larger comparative clinical studies are required to establish the efficacy and safety of topical atorvastatin., (© 2015 S. Karger AG, Basel.)

Importance: Dyskeratosis congenita is a rare disorder that often leads to early death owing to a variety of complications and associated disorders. Early diagnosis and intervention is important in care for patients affected by this disease., Observations: We describe a patient with dyskeratosis congenita (DC) in a child. Our patient had a 3-year history of transaminitis that was felt to be the result of biopsy proven progressive fibrosis of the liver beginning at age 3. He was referred to the dermatology department because of a chronic, evolving eruption with the hope of establishing a unifying diagnosis. Further examination revealed dystrophic nails, numerous dental caries, and blepharitis. Chromosomal analysis on leukocytes showed significant telomere shortening consistent with DC., Conclusions and Relevance: Early recognition and long term care is important in patients with DC because of their propensity to develop malignancy, hematologic abnormalities, and infection. Better understanding of this disease may lead to insights into other disorders associated with abnormal telomere maintenance.

It is proved that chronic ocular surface inflammatory disease (including allergic blepharitis, recurrent chalyazia, punctuate keratitis, recurrent herpetic corneal erosions, late stages of adenoviral keratoconjunctivitis, etc.) takes part in the development of secondary dry eye syndrome (DES). However, therapies for inflammation-induced impairment of tear production do not provide long-term control of inflammatory process. Cyclosporine 0.05% eye drops are an option. Their effect is well-studied in foreign practice. Local application experience of cyclosporine 0.05% eye drops was summarized at a meeting of the Russian expert group on DES and conclusions were made on their effectiveness in treatment of dry eye syndrome associated with certain ocular surface inflammatory disorders, such as allergic blepharoconjunctivitis, late stages of adenoviral keratoconjunctivitis, and others.

Purpose: Population-based cohort study on the risk of anxiety and depression in patients with blepharitis is limited. This study evaluated whether blepharitis patients are at a higher risk of anxiety and depression., Design: A retrospective cohort study., Methods: We used the universal insurance claims data from 1997 to 2010 in Taiwan to identify annually patients with newly diagnosed blepharitis (N = 9764) and without the disease (N = 39056). Incidences, rate ratios (IRR) and hazard ratios (HR) of anxiety and depression were measured for both cohorts by baseline demographic characteristics and comorbidities until the end of 2010., Results: Compared with the non-blepharitis cohort, the blepharitis cohort had higher incidence of anxiety (15.9 vs. 9.5 per 1000 person-years), with an adjusted HR of 1.58 (95% confidence interval (CI) = 1.46-1.70). The incidence of depression was also higher in the blepharitis cohort (7.66 vs. 5.05 per 1000 person-years), with an adjusted HR of 1.42 (95% CI = 1.28-1.58). The blepharitis cohort to the non-blepharitis cohort IRR decreased from 1.73 in the first quartile to 1.32 in the 4(th) quartile for anxiety, and from 1.67 to 1.29 for depression., Conclusions: Patients with blepharitis are at elevated risks of anxiety and depression. The risk is higher in earlier period after the diagnosis of blepharitis, and declines by time, but remains significantly higher for those with blepharitis than those without blepharitis.

Background: Infestation by Demodex spp. in the palpebral edge follicles in humans is common. However, these mites are not routinely diagnosed in patients with or without ocular pathologies in Chile and their relevance is unclear. One of the eye diseases most related to infestation by Demodex spp. is blepharitis, a chronic inflammation of the eyelid margin with intermittent exacerbations, which is very common in ophthalmic practice. Its management is prolonged treatment, which is often ineffective, leading to relapses and frustration of patient and treating physician. Blepharitis can be typed by its etiology into various types, one of them is caused by Demodex folliculorum and another species, D. brevis., Objective: The overall objective was to detect the presence and estimate the rate of infestation of Demodex spp. in healthy subjects and in patients with ocular pathology such as blepharitis, bacterial conjunctivitis, chalazion, and stye., Patients and Methods: Samples of tabs from both lower eyelids of ophthalmologically healthy patients (23) and patients with ocular pathologies (9) were mounted in immersion oil as described in literature, then visualized with a 10x objective and confirmed with 40x objective., Results: Detection rates of eggs, nymphs or adults of Demodex spp. in patients with and without ophthalmological problems were above and below 0.5 mites per tab, respectively. D.folliculorum was the species most frequently found., Discussion: The results are consistent with the international literature on both the rate of infestation as the predominant species., Conclusion: This paper is the first study in Chile on this subject and represents a significant contribution to ophthalmic clinical diagnosis and treatment of patients with this disease.

Aim: To determine the prevalence of various causes of tearing among patients referred to an oculoplastic clinic., Materials and Methods: A prospective study on all patients seen in an oculoplastic clinic with a chief complaint of tearing. The cause of tearing was determined on the basis of the anatomical location of the primary etiology., Results: This study included 357 patients with a mean age 53.9 years. Punctal stenosis was the most common etiology, affecting 37.8% of the patients. Among patients with punctual stenosis, 63.4% were women over 50-year-old (P = 0.001); 55.6% had tearing for less than 6 months (P = 0.038), and all of them had associated chronic blepharitis. The remaining study participants had dry eye with reflex tearing (27.7%), nasolacrimal duct obstruction (10.1%), canalicular obstruction (4.2%), entropion or ectropion (3.4%), pterygium (1.7%), megalo-caruncle (1.7%), and functional tearing (1.7%)., Conclusion: The outcomes of this study indicate the most common cause of tearing is punctal pathology. Therefore, slit lamp evaluation with careful attention to the punctum is warranted in all patients with tearing.

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.

A 7-month-old child presented with a 6-day history of right eyelid swelling and redness. She was being treated with chloramphenicol ointment and oral flucloxacillin by the general practitioner. Clinical examination revealed features of preseptal cellulitis. There was no evidence of orbital involvement and the child was generally well otherwise. Her oral antibiotics were changed and she was adviced to attend for a review in 2 days time. However, the child did not return for a review. Three weeks later following resolution of the eyelid swelling, the child represented with a divergent squint in the right eye. Clinical and orthoptic investigations suggested occlusion amblyopia. The child is currently receiving patching treatment for the amblyopia and is awaiting surgery for squint eye.

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.)

Objective: To assess the changes in eyelid margins associated with eyelid hygiene using Blephaclean eye pads to manage anterior blepharitis or meibomian gland dysfunction (MGD) associated with dry eye complaints., Method: The investigation was a bilateral, prospective, interventional, open-label investigation of 3-month duration. The test population included dry eye sufferers with at least mild symptoms (Ocular Surface Disease Index ≥ 13) who presented with mild to moderate anterior blepharitis or MGD. Eyelid hygiene was intensive (twice a day) for the initial 3 weeks and a maintenance regimen (once a day) for the remainder of the study. At each visit, a detailed assessment of eyelid margins was performed. This assessment included the rating of lashes contamination, lid margin foam, droplet, redness and staining, and meibomian gland blockage, dropout, and expression., Result: Forty subjects aged 22 to 74 years (54 ± 15 years) were enrolled of whom 39 completed the investigation. The product usage revealed good overall compliance throughout the study. The results revealed a significant improvement in eyelid margin status. Significant (P<0.001) decrease in contamination of eyelashes and meibomian gland blockage were recorded at the completion of the initial 3-week intensive phase and maintained over the 3-month study during the maintenance phase. Meibomian gland expression, indicative of the glands functionality, was also significantly better at the completion of both study phases (intensive P=0.003; maintenance P=0.001). A decrease in eyelid margin staining was also observed but was only significant at the 3-month follow-up at the completion of the maintenance phase., Conclusion: The results showed that eyelid hygiene with Blephaclean wipes by subjects with anterior blepharitis or MGD significantly improved the status of the eyelid margin tissues including the meibomian glands. The data confirmed the efficiency of the clinical methodology put forward of 3 weeks of intensive use (twice a day) of eyelid wipes followed by maintenance use (once a day) and that approach achieved a rapid improvement in tissue status and gland patency.

Objective: The principal objective of this investigation was to assess the symptomatic relief associated with eyelid hygiene using Blephaclean eye pads, a cosmetic product, to manage anterior blepharitis or Meibomian gland dysfunction (MGD) associated with dry eye complaints., Method: The investigation was a bilateral, prospective, interventional open label investigation of 3-month duration. The test population was made up of dry eye sufferers with at least mild symptoms (Ocular Surface Disease Index [OSDI] ≥13) who presented with mild to moderate anterior blepharitis or MGD. Eyelid hygiene was intensive (twice a day) for the initial 3 weeks and a maintenance regimen (once a day) for the remainder of the study. At each visit, a detailed assessment of symptomatology was carried out. The assessment included the reporting of overall symptomatology with the OSDI questionnaire, of comfort and specific symptoms at the end of the day on 100-point visual analog scales and of specific MGD-related symptoms on forced choice 5-point scales., Result: Forty subjects aged 22 to 74 years (54±15 years) were enrolled, of whom 39 completed the investigation. The product usage revealed good overall compliance throughout the study. The results revealed significant improvement in symptomatology. A significant (P<0.001) decrease in overall symptomatology was recorded (Mean OSDI: baseline=30, day 21=18, day 90=19; Symptomatic status: baseline 100%, day 21 55%, day 90 54%) associated with significant (P<0.001) increase in the end of day comfort (Mean score: baseline=56, day 21=67, day 90=67) and decrease in end of day dryness (Mean score: baseline=55, day 21=42, day 90=41)., Conclusions: The results showed that eyelid hygiene with Blephaclean wipes by subjects with anterior blepharitis or MGD significantly decreased their associated symptomatology and increased their ocular comfort. The data confirmed the efficiency of the clinical methodology, put forward of 3 weeks of intensive use (twice a day) of eyelid wipes followed by maintenance use (once a day); that approach achieved a rapid symptomatic improvement that was maintained over time.

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.

A complex of measures for lid hygiene in ocular surface disease is developed. These measures together with tear substitution and antibacterial treatment were revealed to result in elimination of blepharoconjunctivitis and dry eye signs, recovery of tear film and long-time remission, that significantly improved patient's life quality. When using this complex of measures meibomian glands are not damaged and their anatomy and functions are completely preserved. Lid hygiene affects all glands, there is no pain and no local anesthesia needed, normal tear film is formed

The aim of this case-control study was to evaluate and compare the bacterial microflora from the conjunctival sac of dogs with atopic dermatitis and healthy dogs. Twenty-one atopic dogs without clinical and/or cytopathological signs of bacterial blepharoconjunctivitis and 21 breed-matched healthy dogs were enrolled. Under topical anaesthesia, the inferior conjunctival sac of one eye was scraped twice. Material was collected with a Kimura spatula, spread over a slide and stained with a Diff Quick(®) -type stain (Medion Diagnostics GmbH, Düdingen, Switzerland) for cytological examination. An area of 0.5 cm(2) was examined at ×1000 magnification, and the types and numbers of cells and bacteria were recorded. A bacterial swab was collected and inoculated into culture media for the growth of aerobic bacteria. Before sampling, each atopic dog was evaluated for severity of cutaneous lesions, pruritus and conjunctival inflammation. Significant differences were observed between atopic and healthy dogs for the presence of bacteria on cytology (P = 0.015), keratinized (P = 0.001) and nonkeratinized epithelial cells (P = 0.013), eosinophils (P = 0.019) and lymphocytes (P = 0.008). Bacteria were recovered from 12 atopic dogs and three healthy dogs (P = 0.004). Staphylococcus pseudintermedius was the most commonly isolated species in atopic dogs (seven of 12). In atopic dogs, no significant relation was found between conjunctival bacterial colonization (on cytology and culture) and the severity of any of the clinical parameters. This study suggests differences in conjunctival bacterial colonization and cytological features between atopic and healthy dogs., (© 2011 The Authors. Veterinary Dermatology. © 2011 ESVD and ACVD.)

Background: Posterior blepharitis is an eyelid disease primarily of the meibomian glands. Bacteria and chronic inflammation are contributing factors for meibomian gland disease, which leads to ocular surface and tear film alterations and chronic patient symptoms. Azithromycin 1.0% ophthalmic solution is a broad spectrum topical antibiotic with anti-inflammatory properties. The present study evaluates the efficacy of azithromycin 1.0% ophthalmic solution in the treatment of the clinical signs and symptoms, including vision-related function, associated with meibomian gland dysfunction., Methods: In an open label study, 33 patients with meibomian gland dysfunction were treated with azithromycin 1.0% ophthalmic solution twice a day for two days, then every evening for a total of 30 days. Tear break-up time, corneal staining, conjunctival staining, Schirmer scores with anaesthetic, meibomian gland score and patient's symptom scores were evaluated at baseline and after 30 days of treatment. The Ocular Surface Disease Index (OSDI) was administered at baseline, after two weeks of treatment and after 30 days of treatment., Results: Twenty-six of 33 patients completed the study. Tear break-up time and Schirmer score increased by 52.7 per cent (p < 0.0001) and 24 per cent (p < 0.05), respectively. There was a reduction in corneal and conjunctival staining by 83.2 and 67.9 per cent, respectively (p < 0.0001). Lid margin scores were reduced by 33.9 per cent (p < 0.0001). The patient's symptom score improved from 2.73 at baseline to 2.21 after 30 days of treatment (p < 0.01). The mean OSDI at baseline was 34.44. After two weeks and 30 days of treatment, the ODSI was 14.51 and 13.15 respectively (p < 0.0001)., Conclusion: These results demonstrate clinically and statistically significant improvement in the signs and symptoms associated with posterior blepharitis. Based on these results, azithromycin 1% ophthalmic solution offers a viable option for the treatment of posterior blepharitis., (© 2010 The Authors. Clinical and Experimental Optometry © 2010 Optometrists Association Australia.)

Objective: To evaluate the clinical efficacy and safety of tobramycin/dexamethasone (TobraDex ST ; 'ST') ophthalmic suspension 0.3%/0.05% compared to azithromycin (Azasite) ophthalmic solution (1%) in the treatment of moderate to severe blepharitis/blepharoconjunctivitis., Research Design and Methods: The study was a multicenter, randomized, investigator-masked, and active-controlled, 15-day study. Enrolled in the study were 122 adult subjects (at least 18 years of age) diagnosed with moderate to severe blepharitis/blepharoconjunctivitis, defined by a minimum score of at least '1' for one of the lid signs, one of the conjunctival signs, and one of the symptoms in at least one eye and a minimum global score (total signs and symptoms score) of '5' in the same eye. One group of 61 subjects received ST with instructions to dose 1  drop four times daily (QID) for 14 days. The other group of 61 subjects received azithromycin and dosed with 1 drop twice daily (BID) for 2 days followed by once daily (QD) dosing for 12 days. Visits were conducted at Day 1 (baseline), Day 8 and Day 15. The a priori primary outcome parameter of the study was the seven-item global score defined as the total score of lid margin redness, bulbar conjunctival redness, palpebral conjunctival redness, ocular discharge (0-3 scale), and lid swelling, itchy eyelids, and gritty eyes (0-4 scale). The study utilized standardized, validated photograph control scales developed by Ora, Inc. (Andover, MA)., Clinical Trial Registration: The study was registered at ClinicalTrials.gov under the registry number NCT01102244., Results: A statistically significant lower mean global score (p = 0.0002) was observed in subjects treated with ST compared to subjects treated with azithromycin at Day 8. No serious adverse events were reported during the course of the study in either group., Conclusion: ST provides a fast and effective treatment of acute blepharitis compared to azithromycin. Initial therapy with the combination of tobramycin/dexamethasone provides faster inflammation relief than azithromycin for moderate to severe blepharitis/blepharoconjunctivitis.