
Cornea, Cataract and Refractive Surgery Management
Modern Topical Lid Treatments: Not Your Mother’s Baby Shampoo Severe lid disease in an 75-year-old, previously untreated patient. (Courtesy of Tracy S. Swartz, OD, MS) If lid disease increases after ocular surgery, your patient will likely complain that the surgery “made their eyesworse,” even if the surgery technically went perfectly. While lid hygiene may be the best treatment, compliance is an issue when patients have been using drops for four weeks already. Patients with subjective symptoms are more likely to continue therapy long-term compared to those with clinical signs but no subjective discomfort.¹Specialty lid formulations better address lid disease than baby shampoo or OTC lid scrubs. These include tea tree oil, hypocholorous acid, Abelmoschus esculentus (okra) and topical steroids. Tea tree oil targets Demodex, the mite commonly found in the lashes of elderly patients. Several topical preparations have been used to cure demodex infections. Gao, et al.² reported that 10% povidone-iodine, 75% alcohol, 50% baby shampoo and 4% pilocarpine failed to kill Demodex after extended exposure, while survival time was limited to 15 minutes in 100% alcohol, 100% TTO, 100% caraway oil or 100% dill weed oil. The same author also evaluated efficacy of tea tree oil scrubs in 11 patients with ocular Demodex who received weekly lid scrub with 50% TTO combined with daily lid hygiene with tea tree shampoo. After TTO lid scrub, the Demodex count dropped to zero for two consecutive visits in less than four weeks, in eight of 11 patients.³This is important to note for our patients desiring resolution of symptoms after surgery. Murphy, et al, compared the efficacy of Dr Organic Tea Tree Face Wash, OcuSoft Lid Scrub Plus and in-house microabrasion before nightly lid scrubs with OcuSoft Lid Scrub Plus. OcuSoft Lid Scrub Plus contains Polyaminopropyl Biguanide (PHMB), an antibacterial preservative.⁴Overall, there was no difference in efficacy between the three treatments (p>0.1).⁵ Tea tree oil is available in premoistened wipes, ocular solution, and facial skin cleansers. Okra contains Abelmoschus esculentus. Okra is also known as Lady's Fingers, gombo, or bamje, and belongs to the Malvaceae family. One study found okra to demonstrate antioxidant, anti-inflammatory, immunomodulatory, antibacterial, anticancer, antidiabetic, organ protective and neuropharmacological activities. In addition, the plant also reportedly has lipid-lowering, trypsin inhibitory, hemagglutinating, antiadhesive and antifatigue activities.⁶This plant is used for ulcers and gastritis,⁷ and is known for its hypoglycemic effect.⁸ Reported fungistatic and fungicidal properties were better than ketoconazole in some strains.⁹ Zocular is a commercially available ocular form of Abelmoschus esculentus. The serum is applied to the lids with massage, and cleans the lids with minimal discomfort. Formulations include serum for in-office application and wipes for daily use. Hypoclorous acid 0.01% is rapidly fungicidal, and exhibits antimicrobial actions with minimal adverse effects.^{10, 11} This is important to remember in patients with blebs, prosthetics and artificial corneal implants, where fungal/bacterial infections may occur. Romanowski, et al, looked at the bacteriocidal effects of HCL 0.01% on existing biofilms formed by ocular clinical bacterial isolates. Kill times for Staphylococcus aureus, coagulase-negative staphylococci, and a keratitis isolate of Pseudomonas aeruginosa were 10 minutes or less, with Staphylococcus epidermidis taking 30 minutes. Stroman, et al, evaluated the effect of 0.01% pure hypochlorous acid (HOCl) directly on periocular skin.¹² The researchers reported a >99% reduction in the Staphylococcal load on the surface after treatment. Hypochlorous acid preparations are available in topical gels or sprays, by prescription and over the counter. Topical steroids may also be used to address blepharitis. These should be used short-term only to reduce the risk of intraocular pressure elevation, cataract formation and lightening of the lid skin color. Topical ointments include tobramycin-dexomethosone combinations, flurometholone and loteprednol. Ko, et al. evaluated tear cytokine levels and clinical outcomes in the meibomian gland dysfunction (MGD) of patients wearing an ocular prosthesis treated using topical loteprednol etabonate and eyelid scrubs with warm compresses.¹³ Investigators reported significant reductions in interleukin (IL)-6, interferon-γ, monocyte chemotactic protein-1, IL-8, tumor necrosis factor-α and IL-1β levels (p<0.001 for each cytokine). Clinically, they found statistically significant improvements in ocular symptoms, margin abnormalities, gland expressibility and meibography images. 1. Alghamdi YA, Camp A, Feuer W, et al. Compliance and Subjective Patient Responses to Eyelid Hygiene. Eye Contact Lens. 2017 Jul;43(4):213-217. doi: 10.1097/ICL.0000000000000258. 2. Gao YY, Di Pascuale MA, Li W, et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol. 2005 Nov;89(11):1468-73. 3. Gao YY, Di Pascuale MA, Elizondo A, et al. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. 2007 Feb;26(2):136-43. 4. OCuSOFT FAQ, Fontus Sciences, LLC. http://www.fontussciences.com/resources?topic=ocusoft%20faq&id=1020. 5. Murphy O, O'Dwyer V, Lloyd-McKernan A. The efficacy of tea tree face wash, 1, 2-Octanediol and microblepharoexfoliation in treating Demodex folliculorum blepharitis. Cont Lens Anterior Eye. 2018 Feb;41(1):77-82. doi: 10.1016/j.clae.2017.10.012. Epub 2017 Oct 23. 6. Islam MT. Phytochemical information and pharmacological activities of Okra (Abelmoschus esculentus): A literature-based review. Phytother Res. 2019 Jan;33(1):72-80. doi: 10.1002/ptr.6212. 7. Ortaç D, Cemek M, Karaca T, et al. In vivo anti-ulcerogenic effect of okra (Abelmoschus esculentus) on ethanol-induced acute gastric mucosal lesions. Pharm Biol. 2018 Dec;56(1):165-75. doi: 10.1080/13880209.2018.1442481. 8. Daliu P, Annunziata G, Tenore GC, et al. Abscisic acid identification in Okra, Abelmoschus esculentus L. (Moench): perspective nutraceutical use for the treatment of diabetes. Nat Prod Res. 2019 Jul 8:1-7. doi: 10.1080/14786419.2019.1637874. 9. Petropoulos S, Fernandes Â, Barros L, et al. The chemical composition, nutritional value and antimicrobial properties of Abelmoschus esculentus seeds. Food Funct. 2017 Dec 13;8(12):4733-43. doi: 10.1039/c7fo01446e. 10. Totoraitis K, Cohen JL, Friedman A. Topical approaches to improve surgical outcomes and wound healing: a review of efficacy and safety. J Drugs Dermatol. 2017 Mar 1;16(3):209-212. 11. Odorcic S1, Haas W, Gilmore MS, et al. Fungal Infections After Boston Type 1 Keratoprosthesis Implantation: Literature Review and In Vitro Antifungal Activity of Hypochlorous Acid. Cornea. 2015 Dec;34(12):1599-605. doi: 10.1097/ICO.0000000000000639. 12. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017 Apr 13;11:707-14. doi: 10.2147/OPTH.S132851. 13. Ko JS, Seo Y, Chae MK, et al. Effect of topical loteprednol etabonate with lid hygiene on tear cytokines and meibomian gland dysfunction in prosthetic eye wearers. Eye (Lond). 2018 Feb;32(2):439-45. doi: 10.1038/eye.2017.213.

Cornea, Cataract and Refractive Surgery Management

Modern Topical Lid Treatments: Not Your Mother’s Baby Shampoo

Severe lid disease in an 75-year-old, previously untreated patient. (Courtesy of Tracy S. Swartz, OD, MS)

If lid disease increases after ocular surgery, your patient will likely complain that the surgery “made their eyesworse,” even if the surgery technically went perfectly. While lid hygiene may be the best treatment, compliance is an issue when patients have been using drops for four weeks already. Patients with subjective symptoms are more likely to continue therapy long-term compared to those with clinical signs but no subjective discomfort.¹Specialty lid formulations better address lid disease than baby shampoo or OTC lid scrubs. These include tea tree oil, hypocholorous acid, Abelmoschus esculentus (okra) and topical steroids.

Tea tree oil targets Demodex, the mite commonly found in the lashes of elderly patients. Several topical preparations have been used to cure demodex infections. Gao, et al.² reported that 10% povidone-iodine, 75% alcohol, 50% baby shampoo and 4% pilocarpine failed to kill Demodex after extended exposure, while survival time was limited to 15 minutes in 100% alcohol, 100% TTO, 100% caraway oil or 100% dill weed oil. The same author also evaluated efficacy of tea tree oil scrubs in 11 patients with ocular Demodex who received weekly lid scrub with 50% TTO combined with daily lid hygiene with tea tree shampoo. After TTO lid scrub, the Demodex count dropped to zero for two consecutive visits in less than four weeks, in eight of 11 patients.³This is important to note for our patients desiring resolution of symptoms after surgery.

Murphy, et al, compared the efficacy of Dr Organic Tea Tree Face Wash, OcuSoft Lid Scrub Plus and in-house microabrasion before nightly lid scrubs with OcuSoft Lid Scrub Plus. OcuSoft Lid Scrub Plus contains Polyaminopropyl Biguanide (PHMB), an antibacterial preservative.⁴Overall, there was no difference in efficacy between the three treatments (p>0.1).⁵ Tea tree oil is available in premoistened wipes, ocular solution, and facial skin cleansers.

Okra contains Abelmoschus esculentus. Okra is also known as Lady's Fingers, gombo, or bamje, and belongs to the Malvaceae family. One study found okra to demonstrate antioxidant, anti-inflammatory, immunomodulatory, antibacterial, anticancer, antidiabetic, organ protective and neuropharmacological activities. In addition, the plant also reportedly has lipid-lowering, trypsin inhibitory, hemagglutinating, antiadhesive and antifatigue activities.⁶This plant is used for ulcers and gastritis,⁷ and is known for its hypoglycemic effect.⁸ Reported fungistatic and fungicidal properties were better than ketoconazole in some strains.⁹ Zocular is a commercially available ocular form of Abelmoschus esculentus. The serum is applied to the lids with massage, and cleans the lids with minimal discomfort. Formulations include serum for in-office application and wipes for daily use.

Hypoclorous acid 0.01% is rapidly fungicidal, and exhibits antimicrobial actions with minimal adverse effects.^{10, 11} This is important to remember in patients with blebs, prosthetics and artificial corneal implants, where fungal/bacterial infections may occur.

Romanowski, et al, looked at the bacteriocidal effects of HCL 0.01% on existing biofilms formed by ocular clinical bacterial isolates. Kill times for Staphylococcus aureus, coagulase-negative staphylococci, and a keratitis isolate of Pseudomonas aeruginosa were 10 minutes or less, with Staphylococcus epidermidis taking 30 minutes.
Stroman, et al, evaluated the effect of 0.01% pure hypochlorous acid (HOCl) directly on periocular skin.¹² The researchers reported a >99% reduction in the Staphylococcal load on the surface after treatment. Hypochlorous acid preparations are available in topical gels or sprays, by prescription and over the counter.

Topical steroids may also be used to address blepharitis. These should be used short-term only to reduce the risk of intraocular pressure elevation, cataract formation and lightening of the lid skin color. Topical ointments include tobramycin-dexomethosone combinations, flurometholone and loteprednol. Ko, et al. evaluated tear cytokine levels and clinical outcomes in the meibomian gland dysfunction (MGD) of patients wearing an ocular prosthesis treated using topical loteprednol etabonate and eyelid scrubs with warm compresses.¹³ Investigators reported significant reductions in interleukin (IL)-6, interferon-γ, monocyte chemotactic protein-1, IL-8, tumor necrosis factor-α and IL-1β levels (p<0.001 for each cytokine). Clinically, they found statistically significant improvements in ocular symptoms, margin abnormalities, gland expressibility and meibography images.

1. Alghamdi YA, Camp A, Feuer W, et al. Compliance and Subjective Patient Responses to Eyelid Hygiene. Eye Contact Lens. 2017 Jul;43(4):213-217. doi: 10.1097/ICL.0000000000000258.
2. Gao YY, Di Pascuale MA, Li W, et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol. 2005 Nov;89(11):1468-73.
3. Gao YY, Di Pascuale MA, Elizondo A, et al. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. 2007 Feb;26(2):136-43.
4. OCuSOFT FAQ, Fontus Sciences, LLC. http://www.fontussciences.com/resources?topic=ocusoft%20faq&id=1020.
5. Murphy O, O'Dwyer V, Lloyd-McKernan A. The efficacy of tea tree face wash, 1, 2-Octanediol and microblepharoexfoliation in treating Demodex folliculorum blepharitis. Cont Lens Anterior Eye. 2018 Feb;41(1):77-82. doi: 10.1016/j.clae.2017.10.012. Epub 2017 Oct 23.
6. Islam MT. Phytochemical information and pharmacological activities of Okra (Abelmoschus esculentus): A literature-based review. Phytother Res. 2019 Jan;33(1):72-80. doi: 10.1002/ptr.6212.
7. Ortaç D, Cemek M, Karaca T, et al. In vivo anti-ulcerogenic effect of okra (Abelmoschus esculentus) on ethanol-induced acute gastric mucosal lesions. Pharm Biol. 2018 Dec;56(1):165-75. doi: 10.1080/13880209.2018.1442481.
8. Daliu P, Annunziata G, Tenore GC, et al. Abscisic acid identification in Okra, Abelmoschus esculentus L. (Moench): perspective nutraceutical use for the treatment of diabetes. Nat Prod Res. 2019 Jul 8:1-7. doi: 10.1080/14786419.2019.1637874.
9. Petropoulos S, Fernandes Â, Barros L, et al. The chemical composition, nutritional value and antimicrobial properties of Abelmoschus esculentus seeds. Food Funct. 2017 Dec 13;8(12):4733-43. doi: 10.1039/c7fo01446e.
10. Totoraitis K, Cohen JL, Friedman A. Topical approaches to improve surgical outcomes and wound healing: a review of efficacy and safety. J Drugs Dermatol. 2017 Mar 1;16(3):209-212.
11. Odorcic S1, Haas W, Gilmore MS, et al. Fungal Infections After Boston Type 1 Keratoprosthesis Implantation: Literature Review and In Vitro Antifungal Activity of Hypochlorous Acid. Cornea. 2015 Dec;34(12):1599-605. doi: 10.1097/ICO.0000000000000639.
12. Stroman DW, Mintun K, Epstein AB, et al. Reduction in bacterial load using hypochlorous acid hygiene solution on ocular skin. Clin Ophthalmol. 2017 Apr 13;11:707-14. doi: 10.2147/OPTH.S132851.
13. Ko JS, Seo Y, Chae MK, et al. Effect of topical loteprednol etabonate with lid hygiene on tear cytokines and meibomian gland dysfunction in prosthetic eye wearers. Eye (Lond). 2018 Feb;32(2):439-45. doi: 10.1038/eye.2017.213.