Etiology of Blepharitis
Blepharitis may be acute (ulcerative or nonulcerative) or chronic (meibomian gland dysfunction, seborrheic blepharitis).
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). Bacterial infections typically have more crusting than the viral type, which usually has more of a clear serous discharge.
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 and inflammation (usually along the edges of both eyelids);
Rubbing (a response to itching that can increase conjunctival itching and exacerbate atopic dermatitis [eczema] of the eyelid); or
Contact sensitivity (dermatoblepharoconjunctivitis).
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 Rosacea Rosacea is a chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and, in severe cases, rhinophyma. Diagnosis is based on the characteristic... read more and recurrent hordeola or chalazia Chalazion and Hordeolum (Stye) Chalazia and hordeola (styes) are sudden-onset localized swellings of the eyelid. A chalazion is caused by noninfectious meibomian gland occlusion, whereas a hordeolum usually is caused by infection... read more .
Many patients with seborrheic blepharitis have seborrheic dermatitis Seborrheic Dermatitis Seborrheic dermatitis is a common inflammatory condition of skin regions with a high density of sebaceous glands (eg, face, scalp, sternum). The cause is unknown, but species of Malassezia... read more of the face and scalp 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 Keratoconjunctivitis Sicca Keratoconjunctivitis sicca is chronic, bilateral desiccation of the conjunctiva and cornea due to an inadequate tear film. Symptoms include itching, burning, irritation, and photophobia. Diagnosis... read more , also known as dry eye.
Symptoms and Signs of Blepharitis
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. Symptoms tend to be worse in the early morning than those of keratoconjunctivitis sicca, which tend to be worse toward the end of the day.
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 or misdirection ( trichiasis Trichiasis Trichiasis is an anatomic misalignment of eyelashes, which rub against the eyeball, in a patient with no entropion. Trichiasis is most often idiopathic, but known causes include blepharitis... read more ) of eyelashes.
In acute nonulcerative blepharitis, eyelid margins become edematous and erythematous; eyelashes may become crusted with dried serous fluid.
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 Keratoconjunctivitis Sicca Keratoconjunctivitis sicca is chronic, bilateral desiccation of the conjunctiva and cornea due to an inadequate tear film. Symptoms include itching, burning, irritation, and photophobia. Diagnosis... read more , such as foreign body sensation, grittiness, eye strain and fatigue, and blurring with prolonged visual effort.
Chronic blepharitis can also occur in patients with eyelid carcinoma (especially if blepharitis is unilateral and there is loss of eyelashes) or immune-mediated conditions such as cicatricial ocular pemphigoid.
Diagnosis of Blepharitis
Diagnosis is usually by slit-lamp examination Slit-lamp examination The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more . Chronic blepharitis that does not respond to treatment may require biopsy to exclude eyelid tumors or immune-mediated conditions that can simulate the condition.
Prognosis for Blepharitis
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 of Blepharitis
Antimicrobials for acute ulcerative blepharitis; warm compresses and sometimes topical corticosteroids for acute nonulcerative blepharitis
For chronic blepharitis, treatment of keratoconjunctivitis sicca, warm compresses, cleansing of eyelids, and sometimes topical or systemic antibiotics as clinically indicated
Acute ulcerative blepharitis is treated with an antibiotic ointment (eg, bacitracin/polymyxin B, erythromycin, or gentamicin 0.3% 4 times a day for 7 to 10 days). Acute viral ulcerative blepharitis is treated with systemic antivirals (eg, for herpes simplex, acyclovir 400 mg orally 3 times a day for 7 days; for varicella zoster, famciclovir 500 mg orally 3 times a day or valacyclovir 1 g orally 3 times a day 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 hours, topical corticosteroids (eg, fluorometholone ophthalmic ointment 0.1% 3 times a day for 7 days) can be used.
The initial treatment for both meibomian gland dysfunction and seborrheic blepharitis is directed toward the secondary keratoconjunctivitis sicca Keratoconjunctivitis Sicca Keratoconjunctivitis sicca is chronic, bilateral desiccation of the conjunctiva and cornea due to an inadequate tear film. Symptoms include itching, burning, irritation, and photophobia. Diagnosis... read more . 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.
If needed, additional treatment for seborrheic blepharitis includes gentle cleansing of the eyelid margin (lid scrubs) twice a day with a cotton swab dipped in a dilute solution of baby shampoo (2 to 3 drops in ½ cup of warm water) or with commercially available wipes and washes that contain ingredients such as a gentle eyelid cleanser, tea tree and coconut oils, or hypochlorous acid 0.01%. A topical antibiotic ointment (erythromycin, bacitracin/polymyxin B or drops such as azithromycin 1.0% or 1.5% or sulfacetamide 10% twice a day for up to 3 months) may be added to reduce bacterial counts on the eyelid margin when cases are unresponsive to weeks of eyelid hygiene.
In some cases, oral azithromycin 500 mg per day for 3 days in three cycles with 7-day intervals or a tetracycline (eg, doxycycline 100 mg orally twice a day tapered over 3 to 4 months) may also be effective because it changes the composition of meibomian gland secretions or alters the composition of skin bacteria.
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 keratoconjunctivitis 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.
Consider alternate diagnoses, including eyelid carcinoma, if chronic blepharitis is unilateral.
Supportive treatments are indicated (eg, warm compresses, eyelid cleansing, and treatment of keratoconjunctivitis sicca as needed).
Specific drug treatments can include topical antimicrobials for acute ulcerative blepharitis, systemic antivirals if viral infection is suspected, and topical corticosteroids for persistent acute nonulcerative blepharitis.
Treatment of chronic blepharitis includes treatment of keratoconjunctivitis sicca with tear supplements and, as-needed use of warm compresses and topical or systemic antibiotics.
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Amescua G, Akpek EK, Farid M, et al: Blepharitis preferred practice pattern®. Ophthalmology126(1):P56-P93. doi: 10.1016/j.ophtha.2018.10.019
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