Any optometrists here - please give me more info

[bocboc8]

Hi, my 10 dd has been diagnosed with blepharitis at the beginning of April. She had a limbal phlycten, a delayed reaction due to her blepharitis and was prescribed fusidic acid and steroid eye drops. After completing the course her eyes were fine for a week until her eye inflammation came back again. On the first visit to the hospital, I was not advised by the eye doctors to apply warm compress and lid cleaning so I assum her blepharitis flared up again. Today I had to take her back to the eye hospital because she has another phlycten. The doctor gave me a prescription to treat it and told us to come back in 2 weeks time.

After the second visit to the eye hospital, I had started with warm compress and lid cleaning and her eyes seem to be a lot better. Today was her fourth visit to the eye hospital.

All the eye doctors that my dd has seen had not offered much advice or info. Can any optometrists here offer me some useful advice in preventing her getting any more phlyctens as I would like her to avoid using steroid eye drops.

Many thanks.

The NHS website on blepharitis is good www.nhs.uk/conditions/blepharitis/pages/introduction.aspx. We've been dealing with this since dd was 11, now she's 15, GOS and Moorfields and Oxford Eye Clinic. She has obvious acne rosacea now altho age 11 there was nothing to see. This means allergy/hypersensitivity is a big component of inflammation, and although meibomian glands are cleared by hygiene and warm compress, we have had to eliminate any possible triggers like bathroom products, detergents, dust/mould. Some of her rosacea triggers are gluten, sugar, dairy. I'm mentioning all this in case it helps people think about blepharitis as an allergic as well as infected eyelid margin condition. As above, we've found she's mildly allergic to many eyedrops esp in chronic use, esp the preservatives, and better using normal saline 0.9% for the dry eyes and if she has to use a steroid, preservative free only. Anti-allergy drops and oral antihistamine did nothing because it's a type IV hypersensitivity response and can appear hours even days later as red skin and resulting red eye, meibomian glands not working again. Cyclosporine ointment is an alternative to steroids. Daily warm compress and gentle cleaning are essential for her, without it we are back to square one in 3 days. (We are using a tea tree oil wash for demodex, even around the eyes, and skin antibacterials and this is because she has acne rosacea. Just in case anyone is wondering what a child might be hypersensitive too.)

Just to add, if blepharitis is left untreated or inadequately treated, the cornea starts to suffer and break down so if it's unresolved try another doc, maybe cornea team in a teaching hospital (www.ncbi.nlm.nih.gov/pubmed/20227627 Wong & Nischal 'managing a child with an external ocular disease' or search PubMed 'blepharokeratoconjunctivitis').

Danger signs of unmanaged chronic keratitis include superficial punctate lesions on the epithelium (superficial punctate keratopathy) or sub-epithelial lesions, which can both be misdiagnosed as eg an inherited dystrophy or virus, whereas the cause may be meibomian gland dysfunction due to untreated blepharitis. The eye doc should check meibomian glands and tear break-up time using fluorescein dye at minimum.

This is what the eye docs are fixing when they give tear substitute + antibacterial + steroid eyedrops and recommend warm compress and hygiene regimes and oral flaxseed/fishoil. There may be allergy to eyedrops. Fixing this is a skill. Check the eye pressure at the opticians soon after starting steroid eyedrops in case there is a sudden rise, esp with eg dexamethosone or Prednisolone although this is less likely on eg FML (hospital eye clinic won't do this, they'll just cross their fingers) Be aware that steroid eyedrops have a cataract risk. Unresolved eye inflammation has a worse risk for a child because the cornea behaves differently to an adult and breaks down faster. The eye doc should not ask you to self-medicate but should recommend a steroid tapering regime, then off once inflammation is controlled and MGs are cleared.

If you're not happy get a second opinion and get advice from a good optometrist (optician) about what's not happening and who to see (they can refer). I haven't met a GP yet who has a clue about this, let alone an ophthalmoscope.

[Just a pushy mum dealing with a child with chronic blepharitis]

Hi bocboc8, it's been 2 yr my son is going through similar situations to ur dd. Ur last post was in 2011, please let me know what treatment worked for u as my son keeps having flare ups and have been on various treatment..