Blepharitis

Blepharitis refers to the family of conditions which are characterised by inflammation of the eyelid margin. It can be acute or chronic and occur at all ages but the most commonly encountered variant is adult chronic disease.¹ It can be anatomically divided into anterior disease which primarily affects the lashes and posterior blepharitis which involves the meibomian glands. Anterior blepharitis is broadly divided into staphylococcal blepharitis and seborrhoeic blepharitis which reflects the underlying pathophysiology to a certain degree although there is often overlap in a given individual and it is not unusual for the different entities to be difficult to distinguish clinically in primary care.²

• For many patients, the pathogenesis is unclear and may be different in different forms of the disease.
• Although some skin commensals are found in higher proportions in these patients (notably S. epidermidis, S. aureus, P. acnes and Cornyebacterium spp.), infection is not thought to be a major contributing factor other than in staphylococcal anterior blepharitis.¹
• Seborrhoeic blepharitis is closely associated with seborrhoeic dermatitis and commonly occurs with posterior blepharitis.²
• Meibomian gland dysfunction may contribute to posterior blepharitis. Their oily secretions are deficient or of poor quality, so resulting in increased tear evaporation and dry eyes.¹
• There are some conditions that are known to specifically cause blepharitis including rosacea, herpes simplex or varicella zoster dermatitis, molluscum contagiosum, allergic or contact dermatitis and staphylococcal dermatitis.³ It may rarely complicate atopic eczema.²
• Ultimately, most individuals presenting with blepharitis are thought to have a combination of factors, although some may predominate to give a picture of a particular type of blepharitis.⁴

• Incidence is 1.8 per 1000 per year but the true prevalence is unknown.
• It accounts for 4.5% of all ophthalmological problems.
• All forms are equally common in both sexes other than staphylococcal blepharitis which is more common in women.
• It is a condition which most commonly starts in the fourth and fifth decades of life.

Symptoms

• Sore eyes that are burning and gritty with crusting on waking - usually bilateral and chronic.
• The eye(s) may be red and occasionally, patients complain of epiphora (tearing) or dry eye and photophobia.
• There is frequently contact lens intolerance.
• There may be long periods of exacerbations and remissions.

Signs⁵

There are a number of signs, some characteristic to each type of blepharitis and many overlapping where there is mixed pathology.

• Basal cell carcinoma
• Cellulitis
• Chalazion
• Conjunctivitis
• Contact lens problems
• Dry eye syndrome
• Hordeolum
• Keratoconjunctivitis
• Trichiasis

This is made on examination of the lids:

• Lid skin - this may be slightly inflamed. Look for concurrent dermatological conditions: scaly or flaking (especially in anterior disease), vesicles (associated with herpetic infection), telangiectasia or pustules (such as in patients with rosacea). It is particularly important to look for associated lesions that may be suspicious of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC).
• Lashes - loss frequently occurs in anterior disease and occasionally happens in long-standing posterior disease.
  

  Be wary of localised lash loss: sebaceous gland carcinoma may mimic chronic blepharitis with localised inflammation and lash loss - refer if unsure.

  Look for collarettes or hard scales (staphylococcal disease) and for greasiness (seborrhoeic disease). Trichiasis (in turning of lashes) and poliosis (whitening of lashes) may occur in long-standing disease.
• Lid margin - look for inflammation around the meibomian gland orifices (meibomianitis) or the capping of the meibomian gland orifices (looks like a row of yellow droplets along the lid margin) of meibomian seborrhoea.
• Tear film - this is frequently deficient in most forms of the disease and it may also be foamy in meibomian seborrhoea.
• Conjunctiva - (evert the upper lid) it may be injected, there may be early chalazion formation and scarring can occur in long-standing disease. Associated conjunctivitis may be present.
• Cornea - inferior punctate epithelial erosions, scarring and neovascularisation may all be found in more severe forms of the disease. Thinning and ulceration is rare but sight-threatening and warrants immediate referral.
• Peripheral examination for associated disease such as dermatological problems, completes your assessment.

Complement this with a general examination of the eye as well as checking visual acuities.⁶

There are no specific tests: diagnosis is made on examination. Swabbing may be appropriate in severe or recurrent cases and biopsy is mandatory in cases where malignancy is suspected (such as associated suspicious lesions or eyelash loss, usually - but not exclusively - in the older patient).

Blepharitis may occur on its own or in association with any of the conditions outlined in the differential diagnosis (above), particularly dry eyes (keratoconjunctivitis sicca).¹ It may also be associated with:

• Bacterial infections e.g. impetigo, erysipelas
• Viral infections e.g. molluscum contagiosum, varicella zoster, papilloma virus
• Immune disease e.g. erythema multiforme, pemphigoid, connective tissue disorders
• Dermatoses e.g. psoriasis, icthyosis, erythroderma
• Benign eyelid tumours e.g. actinic keratosis, haemangioma, pyogenic granuloma
• Malignant eyelid tumours e.g. BCC, SCC, melanoma
• Trauma e.g. chemical, thermal, surgical

• Patient information - this condition often runs a protracted course and its containment will largely depend on the patient understanding the nature of the problem and what the management issues are. A dependence on a course of antibiotics with no patient input will result in limited - if any - positive results. Patients should be advised to avoid contact lens wear, particularly during acute inflammatory episodes. However, the patient should also be reassured that this condition is rarely sight threatening and that it should not prevent them from doing all the usual activities of daily living (including swimming unless there is an acute infection) other than restricting the use of make-up; eye-liner is a particular offender.
• Lid hygiene^2,6 - this is the mainstay of treatment and may be sufficient to control simple low grade blepharitis. It should also be used regardless of the need for additional treatment. Lid hygiene should be carried out twice a day in the acute phase and once daily at other times. There are three main aspects to this:
  

  Action Method Rationale Warm compresses Soak a cloth or make-up pad with hot water - apply to each eye for 5 (ideally 10) minutes. Commercial products specifically prepared for this use are available. Loosens collarrettes and crusting which makes subsequent cleansing more comfortable. Also warms the fatty content of the meibomian glands, so making this easier to express during lid massage. Lid massage (more useful for posterior disease) Close lids and gently rotate clean finger along lid, ending in a downward stroke (upper lid) and upward stroke (lower lid). Move along length of each lid. Loosening meibomian gland content and expressing this through the orifices that line the lid margin. Lid cleansing Mix baby shampoo with water (the quantity that works best varies from patient to patient: start with a 50:50 mix and increase or decrease concentration according to effectiveness). Dip cotton bud in and run along margin, cleaning off debris from lash base. Bicarbonate of soda or commercial lid scrubs may also be used. This gets rid of collarettes and debris, so reducing margin inflammation.

• Managing inflammation - all forms of blepharitis benefit from a short course of topical steroids during an acute exacerbation: typically a drop several times a day, tapered over one to three weeks.¹
• Managing infection^2,6 - if there is an infection despite adequate lid hygiene, you may consider a course of antibiotics.
  • Chloramphenicol ointment is the first choice (drops are second choice) or fusidic acid where chloramphenicol is contraindicated e.g. myelosuppression during previous exposure to chloramphenicol, presence of blood dyscrasia, pregnant women - but fine in breastfeeding women.
    • These are helpful in treating acute infections in anterior blepharitis
    • Ointments should not be used in conjunction with contact lens wear
    • They should be used for four to six weeks
    • They should be applied after eyelid hygiene routine
    • Ointment should be rubbed into the lid margin
    • The frequency depends on severity of the infection but twice daily is a good option
  • Meibomitis responds better to systemic antibiotics over a minimum of six weeks (12 weeks provides a prolonged effect). Options include:
    • Tetracycline - 500 mg b.d. for 4 weeks then 250 mg b.d. for 8 weeks
    • Oxytetracycline - 500 mg b.d. for 4 weeks then 250 mg b.d. for 8 weeks
    • Lymecycline - 408 mg o.d. for 12 weeks
    • Doxycycline - 100 mg o.d. for 4 weeks then 50 mg o.d. for 8 weeks
    Avoid if there is likely to be excessive exposure to the sun (risk of photosensitivity), in pregnant or breastfeeding women and in children under the age of 12. In individuals with renal failure, avoid if possible but if they are essential, doxycycline is a safer option in this group (the others are excreted renally). Other risks associated with tetracycline use are benign intracranial hypertension, gastrointestinal disturbances and in women, yeast infections (e.g. vulvovaginal candidiasis) may occur initially.
  • Repeated courses of antibiotics may be necessary.
  • You may find our records on Administration of Drugs to the Eye and Antimicrobial Eye Preparations useful.
• Managing dry eye - this is a problem frequently encountered by patients suffering from blepharitis. The regular use of artificial tears (e.g. q.d.s. but adjust up or down after a trial period of a few days according to symptoms) and lubricants is appropriate. Generally, artificial tears are best used in the day and the thicker lubricants are best administered last thing at night. See our record on dry eye.
• Managing underlying conditions - these should be addressed as appropriate. This may not completely clear the blepharitis, this may go some way towards easing the symptoms and decreasing the intensity of the treatment.
• Referral
  • Associated cellulitis, suspected malignancy and corneal involvement all warrant referral, urgently in the case of cellulitis.
  • If there is a decrease in visual acuity or the patient complains of moderate/severe pain, there may be more than blepharitis going on and referral is the also necessary.
  • Uncertain diagnosis may also benefit from referral, as may the presence of concurrent disease depending on its nature.

Complications involving the lid

• Chalazion formation: this is a meibomian cyst which is chronic and sterile, filled with lipogranulomatous material. These may be multiple and recurrent but long-standing large ones can be removed in a simple minor operative procedure in an eye unit. They can occasionally get infected: this needs to be treated first with systemic antibiotics prior to incision and curettage.
• Stye (external hordeolum):² this is a painful, purulent swelling most prominent on the outside of the eyelid which arises due to staphylococcal infection of the follicle of an eyelash.
• Lid scarring and trichiasis (inward turning of lashes) if chronic.

Complications involving the rest of the eye

• Contact lens intolerance is common.²
• Dry eye syndrome is also common - particularly in posterior blepharitis.
• Conjunctivitis² - results from infiltration of the conjunctiva with bacterial debris from the eyelid.
• Conjunctival cysts (clear fluid-filled blebs) and concretions (little yellow-white fat aggregates embedded in conjunctiva - most often seen on eversion of inferior tarsus). These tend to be asymptomatic but very large concretions may give rise to a foreign body sensation and can be simply removed with a 25G needle under slit-lamp examination with a drop of local anaesthetic in situ.
• Keratitis (corneal inflammation) ± ulceration. Symptoms of a foreign body sensation, pain, a red eye and photophobia would lead you to suspect this and should prompt referral for further assessment.

This is a chronic condition which rarely fully resolves.⁶ However, with careful, patient and continued adherence to lid hygiene measures (this need to be re-iterated on subsequent visits, even if the eyes are feeling comfortable), symptomatic control is good.⁴ It will not permanently damage eyesight if the complications affecting the eyes are treated appropriately.²