1 Fuchs Endothelial Dystrophy

film substitutes without preservatives since these
affect corneal interepithelial tight junctions and
cause severe changes in the conjunctiva with loss
of goblet cells and deterioration of the initial condition
[5]. Other alternatives would be dexpanthenol
or hyaluronic acid-containing eye drops.
Summary for the Clinician
■ Depending on the kind of impairment of
the tear film (lipid phase, watery phase)
suitable preservative-free artificial tears
should be applied at least five times a
day
10.2.3 Immunomodulatory
Treatment
10.2.3.1 Steroids
Severe courses need topical steroids to
achieve improvement, especially in allergical
forms. In other subtypes steroids become necessary
if the cornea shows marginal infiltrates
or phlyctenules [11, 20]. Also, preservative-free
eye drops should be used, e.g., dexamethasone
three times daily for 2 weeks. Due to possible
side effects like secondary glaucoma or cataract
this medication should only be applied at
a low dosage for a limited period of time [11, 29].
10.2.3.2 Cyclosporin
Rubin and Rao found in their prospective randomized
study of 30 patients that posterior blepharitis
improved significantly from the initial study visit
with both cyclosporin (0.05%) treatment and
tobramycin/dexamethasone, with cyclosporin
showing more improvement in secretion quality.
A higher percentage of patients in the cyclosporin
treatment group showed improvement in
their symptoms of blurred vision, burning, and
itching and more cyclosporin-treated patients experienced
resolution of lid telangiectasia [51]. In
another prospective randomized study of 22 patients
with severe steroid-resistant atopic blepha-
10.2 Treatment 195
ritis, Akpek et al. observed significant improvement
in signs and symptoms using cyclosporin A
(CsA; 0.05%) compared with the placebo group
[1]. In contrast to these studies, the prospective
randomized investigation of Perry et al., including
33 patients with posterior blepharitis, did
not reveal any statistically significant difference
in ocular symptoms, lid margin vascular injection,
tarsal telangiectasis, and fluorescein staining,
but instead a statistically significant decrease
in the number of meibomian gland inclusions in
the CsA group compared with the placebo group
[49]. Therefore, CsA seems to be more advantageous
in patients with an underlying abnormality
in their immune response. In our experience, CsA
1 or even 2% two times daily is often necessary to
obtain alleviation of symptoms and signs.
10.2.3.3 FK506 and Pimecrolimus
Mayer et al. demonstrated in 14 consecutive patients
that topical FK506 (0.1%) ointment turns
out to be an excellent therapeutic option for
the treatment of severe atopic blepharitis [39].
The ointment should be used twice daily at the
lids and lid margin. In a lower concentration of
0.03%, also used twice daily, tacrolimus proved
effective in 2 patients with blepharokeratoconjunctivitis
[28]. A possible side effect might be a
higher vulnerability to herpes simplex keratitis
[28]. In selected cases we successfully applied an
alternative medication, pimecrolimus (Elidel®),
twice daily, to the lids.
Summary for the Clinician
■ Steroids (always preservative-free) are
important in the acute phase; in the
chronic phase with fewer or improved
signs of chronic blepharitis immunomodulatory
eye drops like cyclosporin
should be used
■ In addition, FK506 or pimecrolimus
ointment for the lids, including the lid
margin, may be useful