Blepharitis

Blepharitis refers to the family of conditions which are characterised by inflammation of the eyelid margin. It can be anatomically divided into anterior disease which primarily affects the lashes and posterior blepharitis which involves the meibomian glands.

• For most 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, P. acnes and Cornyebacterium species), infection is not thought to be a major contributing factor other than in staphylococcal anterior blepharitis (see below) ¹.
• Meibomian gland dysfunction may contribute to posterior blepharitis.
• 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. ²

Incidence is 1.8 per 1000 per year. It accounts for 4.5% of all ophthalmological problems.³

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.

Signs ⁴

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
• Trachiasis.

This is made on examination of the lids:

• Start with the lid skin which may be slightly inflamed.
  Look for concurrent dermatological conditions: scaley or flaking (especially in anterior disease), vesicles (associated with herpetic infection), telangectasia or pustules (such as in patients with rosacea).
  It is particularily important to look for associated lesions that may be suspicious of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC).
• Look at the lashes: loss frequently occurs in anterior disease and occasionally happens in long-standing posterior disease.³

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

  Look for colarettes or hard scales (staphylococcal disease) and for greasiness (seborrhoeic disease). Trichiasis (inturning of lashes) and poliosis (whitening of lashes) may occur in long-standing disease.
• Next, move to the 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.
• Examine the tear film: this is frequently deficient in most forms of the disease and it may also be foamy in meibomian seborrhoea.
• Look at the conjunctiva (everting 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.
• Finally, examine the 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.

There are no specific test: 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). It may also be associated with ¹:

• Bacterial infections e.g.: impetigo, erysipelas
• Viral infections e.g.: molluscum contagiosum, varicella zoster, papilloma virus
• Immunue 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 restricing the use of make-up.
• Lid hygiene - 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.
  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. Loosens colarrettes 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 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 infection - chloramphenicol ointment (first choice) or fucidic acid (second choice) are helpful in treating acute infections in anterior blepharitis: they should be used for up to a month after the acute symptoms have subsided.
  Meibomitis responds better to systemic antibiotics - a course of tetracyclines (tetracycline 250mg qds for 6-12 weeks or doxycycline 100mg bd for 1 week then od for 6-12 weeks) or erythromycin where tetracyclines are contraindictaed (children under the age of 12, pregnant or breast-feeding mothers) ⁴.
• Managing dry eye - this is a problem frequently encountered by patients suffering from blepharitis.
  The regular use of artificial tears (e.g: qds 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 (e.g: viscotears) and the thicker lubricants (e.g: lacri-lube) are best administered last thing at night.
• 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.

• Conjunctivitis: treat with topical antibiotics (see above).
• 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.
• 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.
• Lid scarring and trichiasis (inward turning of lashes) if chronic.
• 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. However, with careful and patient 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.