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Hi XXXXX have jut now replied to your queries in your previous post.
Hello Dr, yes I saw thank you very much (I thought you had gone offline). I have a couple of questions for you that I am still typing right now...
Do you still want to discuss further or have any more queries ? I will be available here.
Yes, I wanted to know if this meant that I can't wear makeup for the moment? Or forever for that matter?
You should be able yo wear make up once he issue settles down. This would take a couple of weeks to subside with lid massage, warm compresses .
Thank you Dr. The thing is that now that I am on accutane I try not to wash my eye area very often (two times a week maybe) because otherwise my under-eye area skin gets irritated and very dry... So are the warm compresses a must? Or could it be sufficient to do them once every two days in combination with the antibiotic ointment?
That is an excellent question. I would say that the warm compresses should be done atleast twice a day as it helps to reduce puffiness and pent up secretions.
Oh... well then I will try to even though that is not good news for my fragile skin area at the moment, but if I have to I will do it. And also, since I have been applying hydrating eye creams two or three times daily and not washing them very often to keep the moisture, could this be the cause of the blepharitis? It would seem odd to me since I do not touch the eye, but I do try to get the whole area and often aply creams all the way up the eyelash margin. Could there be bacteria getting in there causing the infection? Once again these are specific eye creams, not makeup, and I never get inside my eye...
up to* the eyelash margin
You can apply the lubricating eye ointment at bedtime only while using the eye drops 4 times a day.
You can wash the lids wih warm water every morning .
The creams would not have caused he blepharitis though.
I'm sorry Dr. my internet went offline for a minute...
Ok. No problem.
So did you mean eye drops or eye cream by 'lubricating eye ointment?'
Yes, lubricating eye ointment.
so cream or liquid drops?
Avoid using face creams very close to the eyelid margins.
Liquid lubricating eye drops can be applied 4 times a day.
Oh ok, do you think my meibomianitis and anterior blepharitis could have been caused by the use of creams close to the eyelid margins and the fact that I didn't wash that area often because I wanted it to have moisture? Or are anterior blepharitis and meibomianitis more deeply rooted infections caused by something else?
Meibomitis is not an infection but rather an inflammation of the meibomian glands. Yes, one of the possibilities is that by not washing the eye area after applying the creams, some kind of crusts could have formed. Just ensure that you wash your eye area thoroughly with warm water every morning.
Te keep the eye moist it is more than enough for the eye drops, eye ointment and natural tears to do so.
And these crusts could have caused meibomitis? Also, could I wash the eye area thoroughly at night, and in the morning just use a Q-tip to wash away the tiny crusts (they come off easily)?
No, crusts would not cause meibomitis. But yes, you can wash the eye thoroughly with warm water at night too.
Ok, so if I do the thorough washing at night and not in the morning (just the Q-tip cleaning in the morning), that would be fine?
As the crust come off easily, I don't think it is anything serious ( there are types of blepharitis which are so severe that the crusts just don't come off easily and infact bleed on removal). What you have is just very mild and should get treated easily with the suggested remedies alone. Yes, you can follow this regime for the moment.
Right thank you Dr, so what you meant by 'No, crusts would not cause meibomitis' and ' Yes, one of the possibilities is that by not washing the eye area after applying the creams, some kind of crusts could have formed' is that the creams I applied couldn't have caused meibomitis or blepharitis, but rather could have caused some of the crusting I see in the morning?
Oh that's such good news then! Because I would think that over time maybe bacteria started to form in the cream, as it hadn't been washed for a couple of days, and then infected the eyelid area, but it's good to know that it wouldn't happen this way. But could this lead to demodex though, you said it was rare, but maybe it started breeding because of the cream I would leave on for a couple of days... I hope not but could this be a possible way to get demodex infestation?
It would never start breeding in the cream........... It is a crab louse which infest the pubic hair. It is so rare otherwise also and seen in unhygeinic individuals. So please do stop worrying on this aspect and go ahead with the other suggestions of eyelid care.
Alright thank you Dr, I won't bother you for long I'm sorry about these many questions, but I'd just like to ask you: if I haven't been washing my eye area (though thouroughly washing my face, but washing my hair only twice a week now because of the accutane dryness)- could this be an unhygeinic way of contracting demodex? Or what would you consider 'unhygeinic' then? And could the eye-demodex spread to my face and give me acne?
No, this is definitely NOT unhygeinic . Unhygeinic would mean not bathing daily / not wearing washed clothes/ untidy and so on. Demodex does not infest the face or cause acne.
Right thank you Dr. And lastly, since the crusts in the morning tend to be loose and not stay at the bottom of my eyelashes (they can be found at the ends of my eyelashes-not necessarily at the base) and come off easily, you said that this meant it was nothing too serious, which is good because it means that my anterior blepharitis (which is the one creating the crusts right?) might be easily treatable... But isn't posterior blepharitis, or the meibomiatis I might have, very difficult to treat?
Sorry about referring to the crab louse ( phthiriasis) when you actually asked about the demodex folliculorum . The two are different .
Yes, I was asking about the demodex folliculorum, so what do you think? Could I have this?
Posterior blepharitis too is treatable.
And does the fact that I can see very tiny whiteheads mean that it can only be posterior blepharitis, or could it be something else less serious?
The tiny white heads are due to blocked openings of the meibomian gland ducts which open at the posterior margin of the eyelid.
It is very common to occur and treatable too.
Right, so it can only be meibomiatis type blepharitis or could it be the accutane blocking the openings or another pathology?
Accutane would not have caused the blocking of the ducts. Just like acne , meibomitis can occur due to blocking of the meibomian glands in the eyelids.
Meibomian glands are also type of modified sebaceous glands.
Thank you for your help Dr, I will follow your regimen scrupulously until I see my Dr. I would just like to know if you have seen patients recover quickly, and also completely, from meibomiatis?
Yes, most of the patients respond very well to the suggested remedies within 3-4 weeks.
The only way to confirm whether you have demodex blepharitis is to visit the ophthalmologist who can take 1-2 eyelashes , stain them and see them under a microscope for the demodex.
Ok good to know. So I also won't wear makeup in between that time (no eyeliner etc...) but is under-eye concealer OK if I don't get close to my eyelid margins?
Yes, avoid eyeliner for the moment. An under eye concealer should be OK as long as it is not very close to the eye.
Ok, I will ask my ophtalmologist to do this to see if there are any demodex, what is the name of the dye that is used for the staining of the lashes so that I can ask him? Also, I am very shocked that he didn't notice the blepharitis, because the crusts and mucus came 36 hours after our appointment... It was probably latent when I saw him, how could he have not noticed it? And what are the name of the exams I should ask him to do to see what is exactly the problem/type of blepharitis?
I still feel that it is very unlikely that you have demodex infestation ( it is a chronic condition and would takes weeks to present) and very unlikely that your ophthalmologist would have missed out the eyelid crusting/ flakes. Since the crusts have come after the eye exam, they are more likely to be due to the eye medicines itself . You can ask for a slit lamp exam ( which he would do invariably ) with epilation ( removal of the eyelash with its root).
Even without staining the mites would be visible under the light microscope.
But a weak concentration of fluorescein dye would make it more obvious to be visualised.
Even with the most remote possibility of it being demodex infestation, the suggested lid scrubs would help.The only modification is the use of tea tree oil (50%) for the scrubs for 4 weeks ( this kills the eggs and the mites).
Tobradex eye ointment is used for a week to keep the inflammatory signs under control and prevent bacterial infection.
But all these can only be given once it is proved that there is indeed a demodex infestation.
So until your next visit to the ophthalmologist, just go ahead with the lid scrubs and warm water cleaning of the eyelid with gentle removal of the crusts.
Yes maybe it is due to the eye medicines, they could have given me the meibomiatis...? Maybe because they are 'stronger' lubricating eye drops and I used them more than prescribed (4 drops a day and I sometimes did 6 or 7)... What do you think? Also, we can almost certainly rule out the demodex possibilty right? Because you said he would have noticed it on the slit lamp and as I got the crusts 36 hours later, there would have already been some demodex mites there, ready to come out, when he examined me, right?
Does this make sense? Are there any more questions which I can answer for you?
(Also, I haven't rated you yet because we are still talking, but I have just tipped you on the other conversation we had because you are helping me so well right now...)
Thank you for your kind gesture.
It has always been my pleasure to have answered your queries.
Thank you Dr, it is a great relief to have you and my gesture is only as kind as is the help you have always given me :)
Thank you. Have a good night ( if there is any left over after this long chat.....). Take care.
Thank you Dr! I also just wanted to know lastly, since before when you answered you thought we were talking about crab louse when you said no, if you think that demodex could spread to the face and give it acne? (I read somewhere that they can 'walk' on the skin too...)
Yes, demodex can be one of the causes for acne of the face. They basically reside in the sebaceous glands ( oil secreting glands) which can get blocked resulting in acne and also for the same reason in meibomitis.
And also, I see that there are different types of blepharitis (staphylococcal, herpetic, etc etc...) Could my ophthalmologist see what type of blepharitis I have with a slit lamp or are there any other exams or lab tests he would need to perform to determine what type of blepharitis I have?
But somehow I feel that you do not have demodex infestation of the eyelashes for the simple reason that it would not have caused crust formation within 36 hours. Moreover it is associated with loss of eyelashes, misdirection of eyelashes too.
So the demodex I could have on my eyes could spread eventually to my face?
Haven't heard of spread from eyelash to face but the two can be co-existing.
Right, thank you so much for your help Dr. One last question: is it bad to use lubricating eye drops more than 4 times a day? As I said earlier that is what I have been doing recently ever since I saw the ophthalmologist and I was wondering if that could have been the cause of my meibomiatis...
No there is no harm even if the lubricating drop are used more than 4 times as prescribed.
OK, thank you so much for your help Dr. Before I go there was also just this question asked earlier that I hadn't received an answer for: " And also, I see that there are different types of blepharitis (staphylococcal, herpetic, etc etc...) Could my ophthalmologist see what type of blepharitis I have with a slit lamp or are there any other exams or lab tests he would need to perform in order to determine what type of blepharitis I have? " And is it easy for an ophthalmologist to see blepharitis/demodex infestation with the normal machines or does he need to be a very good ophthalmologist?
Yes there are different types of blepharitis- infective ( staphylococcal) , seborrhoeic blepharitis, meibomitis. Your ophthalmologist would able to identify these on routine eye exam based on the signs . No other specific tests would be needed except for the epilation to look for demodex.
'routine eye exam based on the signs'- do you mean solely based on what I tell him about my symptoms, or based on what he would see on a slit lamp etc?
Based on what he sees on the slit lamp.
OK, thank you Dr. for your time and help. I will let you know what he says when I will have seen him. This has been of great help, and if I do have blepharitis I will follow your great advice :) I wish you all the best, Alice
Thank you and best wishes. Take care, Bye.
Dear Dr, I actually saw the ophthalmologist yesterday and she did not give me an antibiotic ointment, just a lid hygiene regime (though I do have Azithromycin antibiotic eye drops that were originally for my keratitis- but I've seen online that this works also for treating meibomitis too, right? Or should I have some other antibiotic eye drops, ointment for my meibomitis?)
And most of all I wanted to ask you what you thought about this instead of the warm compresses:
(copy/paste the link in your search bar)
The goggles apparently work well by diffusing heat and moisture in a closed chamber to the eyes to unblock the meibomian glands before massaging them... Do you think this could work well, and do the think these goggles or warm compresses are better? Thank you Dr.!
Thank you for the great tips and information Dr! Well, I can actually see the plugged meibomian glands so I guess it is a really bad case then (I don't see any gunk coming out but I can certainly see the tiniest of white heads on my lower inner lid)... Does that mean it won't leave/ will take months or years to leave? What has been your experience with your patients? Also, if ever it turns out there is demodex brevis infestation of my meibomian glands (I have read that it is the toughest kind of blepharitis to get rid off), then there is no cure right?
Thank you Dr! Good to know that you will still help me even now that I have rated you... :)
So, you think that I can get back to normal in about three weeks, also meaning that you've seen patients with bad meibomitis (though I do not get crusting or swelling anymore) heal in that period of time?
Also, I was wondering, will I be able to wear makeup when I heal? I use white eyeliner on the inside of my lower lid, granted I will buy a new and hypoallergenic one, will I have to ban this habit or will I still be able to do this?
And the lid scrub I use is a wipe for the hygiene of sensitive eyelid skin, but if you do answer that I will be able to use white eyeliner once healed, could I use the wipes to remove the makeup on my inner lid (it seems they are made for the surrounding skin but not the inner lid) or would that be too aggressive, and I should actually buy ultra-sensitive eye makeup remover or do you have something to recommend to clean my inner eyelid?
Also, except for lid hygiene there are no topicals you recommend to apply (anti-bacterial ointment, honey (I read an article about a man finding the blepharitis cure with this), tea tree oil, etc?) And since you caracterized my meibomitis as 'bad' because I can see the plugged glands, do I need stronger medication i.e antibiotics?
Thank you Dr., I am glad that you are still here to help, I really needed your advice and tips and everything you say is of great help to me... Also I hope you have a great time with your family :)
I was wondering, since I also have keratitis, the ophthalmologist gave me vitamin a ointment to put near my conjunctiva by pulling on my lid, but it has vaseline, lanolin, and liquid paraffin... And some of it gets on my inner lids as I try to apply it and it's very greasy, should I call my Dr. back and ask him to prescribe something else to me? Because I feel like it could clog my meibomian glands...
And it's so great to hear that I can use makeup now, this won't irritate or clog the surface of the glands and make it worse? Or bring bacteria, because even though I would clean the eyeliners daily, isn't there still a risk?
Does this mean concealer around the eyes is OK as well? And since my under eye area skin is so fragile due to the accutane and daily eye treatments and scrubs, can I apply hydrating cream to the eye?
Haha well yes you got me, I am definitely over-thinking this, and sadly slightly becoming depressed because of it (mostly because I thought I would never be able to wear makeup anymore). So you are giving me great news!
But I am wondering, I know there is staphylococcal meibomitis, couldn't I contract this (and maybe I already did, I haven't done any lab tests yet to see what kind of meibomitis I have) from bacteria in makeup? Or contract demodex infestation from bacteria in makeup?
Alright, thank you so much for your help and for the relief you've given me Dr.! I will go on with your advice now, except do I have to use the baby shampoo if according to my ophthalmologist I don't have anterior blepharitis, and if I use this:
(copy/paste link in search bar)
Also, if staph infection is very common in meibomitis, does this mean that this is the cause of meibomitis? And how does one contract meibomitis then? (Keep in mind that I am on accutane, and that my eyes would hurt terribly and get puffy after very bad dry eye day episodes, that would happen once a week, where it would get so bad that my eyes would get puffy and stay like that for 24 to 36, and the last time it even stayed like that for a little over 48 hours- also accutane gave me keratitis because of the dryness- maybe this will help you judge if there could be an underlying cause related to this in my case ;) )
Thank you again Dr, I would love to press the positive feedback button again but since I have already pressed it for the previous ophthalmologist, I had to pay 79$ again to give you the positive 'excellent ' feedback (because that was the original price of the consultation). And I know from experience that they will ask me this again if I press the button another time, so I hope you don't mind if I don't give another rating since this is so expensive for me...
Thank you so much for everything Dr! Good night, enjoy your family time :)
Oh I'm sorry I just have one last quick question: I am a student so I take notes on my computer during the day at school/ work on my computer when I get home... Since I have keratitis, should I switch to taking notes on paper/ doing my hw on paper to let the cornea heal from it's lesions since computers might make it worse, or is it still OK to spend so many hours looking at the screen?
Thank you Dr, good to know! Also, I noticed this morning that one of my top eyelashes is shorter and does not curb over as much as the other ones. It does not curb towards my eye but it is does seem to be at a slightly lower level and stick out in a straighter manner than the other eyelashes. I tried plucking it out but plucked another eyelash instead. I'm afraid that it will scratch my cornea, do you think with that the way I described it, there is a risk of that? I am seeing my ophthalmologist in two weeks, should I make an earlier appointment now?
Thank you Dr, so it would only be damaging if the eyelash was pointing towards the cornea right?
Right, I was just wondering about this since I have keratitis already and was afraid about it scratching the cornea but good to know it won't, especially since this short eyelash doesn't touch or head towards the eye and it still curves up slightly at the tip (but a lot less than the others, and though it seems to be coming from the same lash line it looks a bit lower and straighter than the other ones), so it's definitely not a worry even though I have keratitis and am on accutane which makes my 'protection' drier/ thinner/ and less resistant?
And my last question was about my eye exams, should I get lab tests done as soon as possible to determine the cause/ kind of blepharitis I have to get the appropriate treatment quickly or should I continue with my current lid hygiene/compress routine, wait and see for improvement, and do the tests later?
Hello Dr., also, how long does a grade 3 corneal staining take to heal? If most of the lesions heal but some become scars, is it still considered grade 3 corneal staining?
I was just guessing, because I have dry but not infectious keratitis... And I wanted to know how long it took to heal because I wanted to get the new breakthrough Lipiflow procedure, basically the cure for meibomitis and any meibomian gland dysfunction. And in order to get it one must not have keratitis that is too acute so forget about the corneal staining question, I wanted to know from your experience how long dry keratitis can take to heal?
Here is quick info on the treatment in case you are interested, you can read more about it online if you wish: "LipiFlow Thermal Pulsation technology applies controlled heat to the inner eyelid, and mild intermittent pressure releasing lipids from the blocked Meibomian glands. LipiFlow treats the upper and lower eyelids simultaneously." It releases years of blocked meibum and debris from the meibomian glands and gets them working again, this can last one or two years, and can heal things for good if you keep good lid hygiene. The patient reviews I've come across on various websites are amazing.
Do you think I should consult now, because it says that the earlier the better? Or should I wait until I am done with accutane to try and get it? (Let me know what you think, but personally I would like to think that it would be best to get it now and keep doing the hot compresses afterward so that the glands stay healthy until the end of the treatment, and even maybe continue after...)
Thank you Dr.!
Thank you for your help Dr.! I am a little depressed as I feel like I can see the 'tiny whiteheads' of my clogged meibomian glands more and more (though maybe this could mean things are coming out? Highly doubt it but who knows)... I have been doing the warm compresses once a day and cleaning the eyelids with baby shampoo twice a day though... And according to you, being able to see the meibomian glands means I am in the most severe case of meibomitis. So I'm kind of starting to lose hope, and since I don't want to stop living I am wondering, do I have to eradicate my severe meibomitis? Can I go on with the prescribed treatment, wearing my makeup like you said I could, just not worrying about it too much, and not be frustrated because if it never gets better? I have drops to hydrate my eyes so they don't hurt at all, my eyelids aren't red (though I do have two or three tiny red 'scars') or puffy and my waterline isn't red either, I don't having crusting or scaling... So maybe I can just stop stressing all the time about this and go about with my life? I guess what I want to know is: could there be any complications over time (might I end up eventually getting these flakes/scales/etc... or maybe even styes or chazalions) if my meibomitis doesn't heal, granted that of course I will still keep doing the daily lid hygiene routine? Of course I am seeking peace of mind, but I would rather you be completely honest with me even if the news is bad... Thank you again for your time Dr.