DEBS – a unification theory for dry eye and blepharitis

Abstract

For many years, blepharitis and dry eye disease have been thought to be two distinct diseases, and evaporative dry eye distinct from aqueous insufficiency. In this treatise, we propose a new way of looking at dry eye, both evaporative and insufficiency, as the natural sequelae of decades of chronic blepharitis. Dry eye is simply the late form and late manifestation of one disease, blepharitis. We suggest the use of a new term in describing this one chronic disease, namely dry eye blepharitis syndrome (DEBS). Bacteria colonize the lid margin within a structure known as a biofilm. The biofilm allows for population densities that initiate quorum-sensing gene activation. These newly activated gene products consist of inflammatory virulence factors, such as exotoxins, cytolytic toxins, and super-antigens, which are then present for the rest of the patient’s life. The biofilm never goes away; it only thickens with age, producing increasing quantities of bacterial virulence factors, and thus, increasing inflammation. These virulence factors are likely the culprits that first cause follicular inflammation, then meibomian gland dysfunction, aqueous insufficiency, and finally, after many decades, lid destruction. We suggest that there are four stages of DEBS which correlate with the clinical manifestations of folliculitis, meibomitis, lacrimalitis, and finally lid structure damage evidenced by entropion, ectropion, and floppy eyelid syndrome. When one fully understands the structure and location of the glands within the lid, it becomes easy to understand this staged disease process. The longer a gland can resist the relentless encroachment of the invading biofilm, the longer it can maintain normal function. The stages depend purely on anatomy and years of biofilm presence. Dry eye now becomes a very easy disease to understand. We feel that dry eye should be treated and prevented by early and routine biofilm removal through electromechanical lid margin debridement.

In vitro antimicrobial activity of a new ophthalmic solution containing povidone‐iodine 0.6% (IODIM®)

“…Bacteria and fungi can exist simply as free‐floating planktonic single cells or form biofilm, a structured community of organisms enclosed in a self‐produced polymeric matrix and adherent to the surface of tissues and biomaterials (Costerton et al. ; Rynerson & Perry ). According to a basic model of biofilm structure, bacteria and fungi form microcolonies bound together by a copious amount of exopolysaccharide and surrounded by water‐filled channels that deliver nutrients and remove waste products (Rynerson & Perry ).…”

“…; Rynerson & Perry ). According to a basic model of biofilm structure, bacteria and fungi form microcolonies bound together by a copious amount of exopolysaccharide and surrounded by water‐filled channels that deliver nutrients and remove waste products (Rynerson & Perry ). In vitro experiments have demonstrated that microbial biofilms are considerably less susceptible to antimicrobial agents than their planktonic counterparts (Imamura et al.…”

“…). Growing evidence indicates that microbial biofilm plays a role in a variety of ocular infections, including chronic blepharitis (Rynerson & Perry ), non‐contact lens‐related keratitis (Pinna et al. ), contact lens‐associated keratitis (Zegans et al.…”

Ocular surface inflammation impairs structure and function of meibomian gland

“…Rynerson and Perry proposed a clinical entity named as DEBS (dry eye and blepharitis). Blepharitis caused by bacterial colonization in the lid margin could cause follicular inflammation, then MGD (Rynerson and Perry, 2016). Blepharokeratoconjunctivitis also causes loss of the gland as evaluated by non-invasive meibography (Yin and Gong, 2016).…”

Analysis of the Pathogenic Factors and Management of Dry Eye in Ocular Surface Disorders

“…Furthermore, an infection with commensal bacteria such as Staphylococcus aureus is one of the causes of chronic blepharitis. Recent studies suggested a new term to describe it as an only chronic disease called dry eye blepharitis syndrome (DEBS) [10]. It's an inflammatory condition of the eyelid margin previously considered synonymous with MGs dysfunction but in recent years recognized as a clinical conditions that may develop in the later stages of MGs dysfunction or independently, where the DE is the ultimate manifestation of the disease.…”