What procedures can be administered to repair deformity in a patient with chronic blepharitis, possible Demodex infestation, and a history of autoimmune conditions like vitiligo?

Surgical and Procedural Interventions for Eyelid Deformity in Chronic Blepharitis

For eyelid deformities secondary to chronic blepharitis, surgical correction is indicated when structural abnormalities compromise ocular surface health or visual function, including procedures for ectropion, entropion, trichiasis, and eyelid margin reconstruction. 1

Identifying Deformities Requiring Surgical Repair

The following structural abnormalities warrant consideration for surgical intervention:

Eyelid Malposition

• Ectropion (outward turning of eyelid) and entropion (inward turning of eyelid) develop from chronic inflammation and scarring in severe blepharitis 1
• Lagophthalmos (incomplete eyelid closure) increases tear evaporation and requires evaluation for surgical correction 1
• Eyelid laxity assessment is critical, as chronic inflammation weakens eyelid structural integrity 1

Eyelash Abnormalities

• Trichiasis (misdirected eyelashes) results from eyelid margin scarring and causes corneal damage 1
• Loss or breakage of eyelashes may indicate severe anterior blepharitis with follicular destruction 1

Eyelid Margin Pathology

• Scarring and fibrosis of the posterior eyelid margin with meibomian gland obliteration 1
• Eyelid margin keratinization and thickening 1
• Cicatricial changes including fornix foreshortening and symblepharon formation 1

Surgical Procedures for Deformity Repair

For Eyelid Malposition

• Ectropion repair through horizontal eyelid tightening procedures or full-thickness skin grafting when cicatricial changes are present 1
• Entropion correction via eyelid margin rotation procedures or tarsal fracture techniques 1
• Lagophthalmos correction may require eyelid lengthening or gold weight implantation in severe cases 1

For Trichiasis and Eyelash Abnormalities

• Electrolysis or cryotherapy for isolated misdirected lashes 1
• Eyelid margin rotation procedures for diffuse trichiasis 1
• Mucous membrane grafting when extensive eyelid margin scarring is present 1

For Meibomian Gland Dysfunction and Scarring

• In-office procedural treatments including vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 2
• Meibomian gland probing may be considered for obstructed glands, though this is not universally recommended 1

Critical Pre-Surgical Considerations

Rule Out Malignancy

• Eyelid biopsy is mandatory for chronic unilateral blepharitis unresponsive to therapy, marked asymmetry, or unifocal recurrent chalazia, as carcinoma can masquerade as blepharitis 1, 3
• Sebaceous gland carcinoma particularly mimics chronic blepharitis and requires high clinical suspicion 1

Optimize Medical Management First

• Address active inflammation with warm compresses, eyelid hygiene, and topical antibiotics before elective surgery 2
• Treat Demodex infestation if present, as cylindrical dandruff at eyelash bases is pathognomonic 4, 5
• Consider short-term topical corticosteroids (loteprednol etabonate or fluorometholone) for severe inflammation prior to surgery 2

Pre-Operative Risk Mitigation

• Moderate to severe blepharitis increases endophthalmitis risk after intraocular surgery and should be treated aggressively beforehand 3
• Consider topical antibiotics like ofloxacin when preparing for any intraocular procedure 2

Special Considerations for Autoimmune Patients

Given the history of vitiligo (an autoimmune condition):

• Autoimmune patients may have more severe ocular surface inflammation requiring aggressive pre-operative control 1
• Graft-versus-host disease and other autoimmune conditions are associated with cicatricial blepharitis requiring more extensive surgical reconstruction 1
• Post-operative healing may be compromised; plan for extended follow-up 1

Pediatric Considerations

Important caveat: Severe blepharitis in children can lead to corneal ulceration and perforation more frequently than in adults, and pediatric blepharokeratoconjunctivitis is often unrecognized and can cause amblyopia 1, 3

Post-Surgical Management

• Continue long-term eyelid hygiene as blepharitis is chronic with periods of exacerbation and remission 2, 3
• Daily warm compresses and eyelid cleansing remain essential even after surgical correction 2
• Monitor for recurrence of deformity, as ongoing inflammation can cause progressive structural changes 1