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Blepharitis

by James Garrity, MD

Blepharitis is inflammation of the eyelid margins that may be acute or chronic. Symptoms and signs include itching and burning of the eyelid margins with redness and edema. Diagnosis is by history and examination. Acute ulcerative blepharitis is usually treated with topical antibiotics or systemic antivirals. Acute nonulcerative blepharitis is occasionally treated with topical corticosteroids. Chronic disease is treated with tear supplements, warm compresses, and occasionally oral antibiotics (eg, a tetracycline) for meibomian gland dysfunction or with eyelid hygiene and tear supplements for seborrheic blepharitis.

Etiology

Blepharitis may be acute (ulcerative or nonulcerative) or chronic (meibomian gland dysfunction, seborrheic blepharitis).

Acute

Acute ulcerative blepharitis is usually caused by bacterial infection (usually staphylococcal) of the eyelid margin at the origins of the eyelashes; the lash follicles and the meibomian glands are also involved. It may also be due to a virus (eg, herpes simplex, varicella zoster).

Acute nonulcerative blepharitis is usually caused by an allergic reaction involving the same area (eg, atopic blepharodermatitis and seasonal allergic blepharoconjunctivitis, which cause intense itching, rubbing, and a rash; or contact sensitivity [dermatoblepharoconjunctivitis]).


Chronic

Chronic blepharitis is noninfectious inflammation of unknown cause. Meibomian glands in the eyelid produce lipids (meibum) that reduce tear evaporation by forming a lipid layer on top of the aqueous tear layer. In meibomian gland dysfunction, the lipid composition is abnormal, and gland ducts and orifices become inspissated with hard, waxy plugs. Many patients have rosacea (see Rosacea) and recurrent hordeola or chalazia (see Chalazion and Hordeolum (Stye)).

Many patients with seborrheic blepharitis have seborrheic dermatitis of the face and scalp (see Seborrheic Dermatitis) or acne rosacea. Secondary bacterial colonization often occurs on the scales that develop on the eyelid margin. Meibomian glands can become obstructed.

Most patients with meibomian gland dysfunction or seborrheic blepharitis have increased tear evaporation and secondary keratoconjunctivitis sicca (see Keratoconjunctivitis Sicca).


Symptoms and Signs

Symptoms common to all forms of blepharitis include itching and burning of the eyelid margins and conjunctival irritation with lacrimation, photosensitivity, and foreign body sensation.

Acute

In acute ulcerative blepharitis, small pustules may develop in eyelash follicles and eventually break down to form shallow marginal ulcers. Tenacious adherent crusts leave a bleeding surface when removed. During sleep, eyelids can become glued together by dried secretions. Recurrent ulcerative blepharitis can cause eyelid scars and loss of eyelashes.

In acute nonulcerative blepharitis, eyelid margins become edematous and erythematous; eyelashes may become crusted with dried serous fluid.


Chronic

In meibomian gland dysfunction, examination reveals dilated, inspissated gland orifices that, when pressed, exude a waxy, thick, yellowish secretion. In seborrheic blepharitis, greasy, easily removable scales develop on eyelid margins. Most patients with seborrheic blepharitis and meibomian gland dysfunction have symptoms of keratoconjunctivitis sicca, such as foreign body sensation, grittiness, eye strain and fatigue, and blurring with prolonged visual effort.


Diagnosis

  • Slit-lamp examination

Diagnosis is usually by slit-lamp examination. Chronic blepharitis that does not respond to treatment may require biopsy to exclude eyelid tumors that can simulate the condition.

Prognosis

Acute blepharitis most often responds to treatment but may recur, develop into chronic blepharitis, or both. Chronic blepharitis is indolent, recurrent, and resistant to treatment. Exacerbations are inconvenient, uncomfortable, and cosmetically unappealing but do not usually result in corneal scarring or vision loss.

Treatment

  • Supportive measures (eg, treatment of keratoconjunctivitis sicca, warm compresses, cleansing of eyelids) as clinically indicated

  • Antimicrobials for acute ulcerative blepharitis

Acute

Acute ulcerative blepharitis is treated with an antibiotic ointment (eg, bacitracin/polymyxin B, erythromycin, or gentamicin 0.3% qid for 7 to 10 days). Acute viral ulcerative blepharitis is treated with systemic antivirals (eg, for herpes simplex, acyclovir 400 mg po tid for 7 days; for varicella zoster, famciclovir 500 mg po tid or valacyclovir 1 g po tid for 7 days).

Treatment of acute nonulcerative blepharitis begins with avoiding the offending action (eg, rubbing) or substance (eg, new eye drops). Warm compresses over the closed eyelid may relieve symptoms and speed resolution. If swelling persists > 24 h, topical corticosteroids (eg, fluorometholone ophthalmic ointment 0.1% tid for 7 days) can be used.


Chronic

The initial treatment for both meibomian gland dysfunction and seborrheic blepharitis is directed toward the secondary keratoconjunctivitis sicca (see Keratoconjunctivitis Sicca). Tear supplements during the day, bland ointments at night, and, if necessary, punctal plugs (inserts that obstruct the puncta and thus decrease tear drainage) are effective in most patients.

If needed, additional treatment for meibomian gland dysfunction includes warm compresses to melt the waxy plugs and occasionally eyelid massage to extrude trapped secretions and coat the ocular surface. A tetracycline (eg, doxycycline 100 mg po bid tapered over 3 to 4 mo) may also be effective because it changes the composition of meibomian gland secretions or alters the composition of skin bacteria.

If needed, additional treatment for seborrheic blepharitis includes gentle cleansing of the eyelid margin 2 times a day with a cotton swab dipped in a dilute solution of baby shampoo (2 to 3 drops in ½ cup of warm water). A topical antibiotic ointment (bacitracin/polymyxin B or sulfacetamide 10% bid for up to 3 mo) may be added to reduce bacterial counts on the eyelid margin when cases are unresponsive to weeks of eyelid hygiene.


Key Points

  • Common forms of blepharitis include acute ulcerative (often secondary to staphylococcal or herpes virus infection), acute nonulcerative (usually allergic), and chronic (often with meibomian gland dysfunction or seborrheic dermatitis).

  • Secondary conjunctivitis sicca usually accompanies chronic blepharitis.

  • Common symptoms include itching and burning of the eyelid margins and conjunctival irritation with lacrimation, photosensitivity, and foreign body sensation.

  • Diagnosis is usually by slit-lamp examination.

  • Supportive treatments are indicated (eg, warm compresses, eyelid cleansing, and treatment of keratoconjunctivitis sicca as needed).

  • Specific treatments can include antimicrobials for acute ulcerative blepharitis and sometimes chronic blepharitis and topical corticosteroids for persistent acute nonulcerative blepharitis.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ACHROMYCIN V
  • ZOVIRAX
  • ERY-TAB, ERYTHROCIN
  • FAMVIR
  • GENOPTIC
  • BACIIM
  • VALTREX
  • PERIOSTAT, VIBRAMYCIN
  • BLEPH-10

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