It can be difficult not to feel disgruntled when a patient with 20/20 visual acuity is not happy postoperatively due to a persistent foreign body sensation and/or ocular irritation. As patients' expectations continue to increase, we surgeons must become more aggressive about treating the potential causes of their postoperative dissatisfaction. Blepharitis can be a factor in the tear film's dysfunction. Furthermore, an abnormal tear film results in the degradation of image quality.¹ Diagnosing blepharitis and beginning its treatment prior to surgery is preferable, but treating blepharitis after cataract surgery may improve the tear film and thereby enhance patients' comfort and visual function.

It is important to evaluate patients for other conditions that may affect their tear film, such as dry eye and ocular allergy. Both can be ruled out by carefully examining the conjunctiva for an inflammatory reaction and performing a Schirmer test. Blepharitis can present in conjunction with the aforementioned problems, in which case all conditions should be treated.

LOCATION AND TREATMENT OF BLEPHARITIS
The AAO's 2008 Preferred Practice Patterns² divide blepharitis into its anatomic locations, anterior including the lashes and posterior including the meibomian glands. Frequently, a patient will have elements of both anterior and posterior blepharitis, but we should directly treat what appears to be the most prominent.

With anterior blepharitis, patients may have significant lid debris or collarettes on their lashes. Madarosis or even matting of the lashes may also be evident. Treatment (traditionally lid scrubs with dilute baby shampoo) is often directed at the removal of all matter.³ Several companies have introduced additional products for treatment such as Ocusoft Lid Scrub Eyelid Cleanser (Cynacon/Ocusoft, Rosenberg, TX) and TheraTears SteriLid (Advanced Vision Research, Woburn, MA). Baby shampoo and similar products should not be used by patients who do not have anterior blepharitis, as the detergents may further destabilize the tear film.

An important cause of anterior blepharitis is the overgrowth of Demodex. Although many believe Demodex to be part of the normal ocular flora,⁴ treating the eyelids with tea tree oil results in a decreased load of demodex and improves both the symptoms and signs of anterior blepharitis.⁵

We can detect posterior blepharitis as inspissations of the meibomian glands. Other findings can include lid telangiectasias, a frothy tear film, or a "toothpaste sign" (ie, the expression of thickened meibomian gland secretions via pressure on the lid margin). Traditional therapy includes warm compresses and lid massages to loosen the meibomian gland secretions.

Additional treatments include antibiotic and anti-inflammatory therapy. Antiobiotics not only decrease bacterial overgrowth on the ocular surface, but they also improve the meibomian gland's function. Oral minocycline has been found to alter the meibomian fatty acids,⁶ and tetracycline has been shown to inhibit lipase production.⁷ In fact, tetracycline is extremely effective in the treatment of blepharitis associated with ocular rosacea.⁸ Recently, topical azithromycin (Azasite; Inspire Pharmaceuticals, Inc., Durham, NC) has been reported to decrease the inflammatory signs seen in blepharitis.⁹ Anti-inflammatory therapy is also very effective in the treatment of blepharitis. It can take the form of traditional steroid drops, nontraditional steroid drops such as loteprednol (Lotemax; Bausch & Lomb, Inc. Rochester, NY), or cyclosporine (Restasis; Allergan, Inc., Irvine, CA).¹⁰

Nutritional therapy, such as flaxseed oil and omega-3 fatty acid supplementation, may also improve the quality of the meibomian gland's secretions.¹¹

As important as choosing the proper therapy is avoiding improper therapy. Punctal plugs, for example, will keep the inflammatory mediators of the tear film on the ocular surface in eyes with significant blepharitis. Plugs may be considered once the inflammatory component is under control.¹²

CONCLUSION
The majority of my patients with blepharitis after cataract surgery have a posterior component. I treat them with a combination antibiotic/steroid medication such as tobramycin/dexamethasone (Tobradex; Alcon Laboratories, Inc., Fort Worth, TX) or tobramycin/loteprednol (Zylet; Bausch & Lomb, Inc.), both of which are effective in managing blepharitis.¹³ Because the long-term use of steroids can lead to increased IOP, I transition patients to another medication once the inflammatory component is under control.

Patients with blepharitis after cataract surgery represent a distinct challenge. By appropriately stabilizing their tear film and improving their vision, we can transform these individuals into some of our most appreciative patients.

David A. Goldman, MD, is an assistant professor of clinical ophthalmology at the Bascom Palmer Eye Institute in Palm Beach Gardens, Florida. He serves as a consultant to Alcon Laboratories, Inc. He has also received research support from the ASCRS Foundation. Dr. Goldman may be reached at (561) 515-1543; dgoldman@med.miami.edu.

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