This is often associated with excess ‘sleep’ and lashes debris. It almost always involves marginal blepharitis and meibomian gland dysfunction, with an associated tear film instability.

Emphasize slit-lamp evaluation of the cornea and look for:

• Inferior corneal hazing
• Small fascicular pannus ingrowths or ‘ghosts’
• Punctate fluorescein staining
• Rapid tear breakup times.

Management

Lubrication and lavage especially at bedtime (use viscous drops) and immediately upon waking (use several drops of non-viscous solution).

Emphasize the value of lid hygiene (lid scrubs).

Emphasize the value of hot pack applications.

Consider diagnostic punctal occlusion with collagen plugs.

Consider more permanent occlusion if signs and symptoms are significantly improved.

Consider oral tetracycline if the staining is severe.