AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Blepharitis refers to a family of inflammatory disease processes of the eyelid(s).

Blepharitis can be divided anatomically into anterior and posterior blepharitis. Anterior blepharitis refers to inflammation mainly centered around the eyelashes and follicles, while the posterior variant involves the meibomian gland orifices. Anterior blepharitis usually is subdivided further into staphylococcal and seborrheic variants.

Frequently, a considerable overlap exists in these processes in individual patients. Blepharitis often is associated with systemic diseases, such as rosacea and seborrheic dermatitis, as well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis, conjunctivitis, and keratitis.

Pathophysiology

The pathophysiology of blepharitis usually involves bacterial colonization of the eyelids. This results in direct microbial invasion of tissues, immune system–mediated damage, or damage caused by the production of bacterial toxins, waste products, and enzymes. Colonization of the lid margin is increased in the presence of seborrheic dermatitis or meibomian gland dysfunction.

Frequency

United States

Blepharitis is a common eye disorder in the United States and throughout the world.

Mortality/Morbidity

The exact association between blepharitis and mortality is not known, but diseases with known mortality, such as systemic lupus erythematosus, may have blepharitis as part of their constellation of findings. Associated morbidity includes loss of visual function, well-being, and ability to carry out daily life activities. The disease process can result in damage to the lids with trichiasis, notching entropion, and ectropion. Corneal damage can result in inflammation, scarring, loss of surface smoothness, and loss of optical clarity. If severe inflammation develops, corneal perforation can occur.

Race

No known studies demonstrate racial differences in the incidence of blepharitis. Rosacea may be more common in fair-skinned individuals, although this finding may be only because it is more easily and frequently diagnosed in these individuals.

Sex

No well-designed studies of differences in the incidence and clinical features of blepharitis between the sexes have been found.

Age

Seborrheic blepharitis is more common in an older age group. The apparent mean age is 50 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients with blepharitis typically present with symptoms of eye irritation, itching, erythema of the lids, and/or changes in the eyelashes.

• Common complaints include the following:
• • Burning
  • Watering
  • Foreign body sensation
  • Crusting and mattering of the lashes and medial canthus
  • Red lids
  • Red eyes
  • Photophobia
  • Pain
  • Decreased vision

• The condition most typically has a chronic course with intermittent exacerbations and eruptions of symptomatic disease. Seborrheic dermatitis can be associated with symptoms of scalp itching, flaking, and oily skin. Rosacea can be associated with a red and swollen nose (rhinophyma), facial flushing, broken and distended vessels in the face, pustules, oily skin, and eye irritation.

Physical

• External examination of patients with blepharitis often demonstrates findings of associated conditions. Herpetic skin disease can be associated with erythema and vesicle formation. Seborrheic dermatitis is typified by oily skin and flaking from the scalp or brows. Rosacea is associated with pustules, rhinophyma, telangiectasias, erythema, and pustules.
• Gross examination of the eyelids shows erythema and crusting of the lashes and lid margins.
• Slit lamp examination shows additional features, including loss of lashes (madarosis), whitening of the lashes (poliosis), scarring and misdirection of lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid margin ulcers, plugging and "pouting" of the meibomian orifices, telangiectasias, and lid irregularity (tylosis).
• The conjunctiva usually shows papillary injection.
• Corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal ulcers, pannus, and phlyctenule formation. Corneal involvement occurs most commonly at the positions where the limbus is crossed by the upper and lower lid margins, at the 2-, 4-, 8-, and 10-o'clock positions. Corneal infiltrates can progress to infection and even perforation.
• The anterior variant of blepharitis involves mainly the lashes and associated oil glands. Various formations of debris adhere to the lashes.
• • Crusting refers to flakes of material that adhere to the lashes and usually represents seborrheic disease. The epithelial material is often referred to as scurf.
  • A collarette is a ringlike formation around the lash shaft that occurs with staphylococcal disease. Staphylococcal blepharitis is typified by the formation of collarettes on the lashes.
  • A sleeve is a tube of material that also surrounds the lash. Sleeving is associated with infection by the eyelash parasite, Demodex.
  • Ulcers form at the base of the lashes. They are covered by a crust of fibrin, which is lifted up as the lash shaft grows.
  • Seborrheic blepharitis also involves primarily the anterior lid and is associated with the formation of greasy crusts of material, which are adherent to the eyelash shaft.

• Corneal disease is most common with the staphylococcal variant of anterior lid disease.
• Posterior blepharitis mainly is related to dysfunction of the meibomian glands. Alterations in secretory metabolism and function lead to disease. The meibomian secretions become more waxlike and begin to block the gland orifices. The stagnant material becomes a growth medium for bacteria and can seep into the deeper eyelid tissue layers, causing inflammation. These processes lead to gland plugging, inspissated material, inflamed orifices, and formation of chalazia.
• Various corneal changes can also result from posterior blepharitis.

Causes

• Some specific causes of blepharitis may include the following:
• • Rosacea
  • Herpes simplex dermatitis
  • Varicella-zoster dermatitis
  • Molluscum contagiosum
  • Allergic or contact dermatitis
  • Seborrheic dermatitis
  • Staphylococcal dermatitis

• Chronic blepharitis has been associated with exposure to chemical fumes, smoke, smog, and other irritants.
• Acute blepharitis is most commonly due to allergic drug or chemical reaction.
• Sjogren syndrome may present as blepharitis.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Seborrheic dermatitis
Rosacea
Herpetic eye disease

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• In general, diagnostic tests do not typically need to be performed for suspected blepharitis. Research and other rare protocols may involve eyelid margin cultures, transillumination studies of the meibomian glands, marginal biopsies, or even analysis of gland secretions.
• Testing patients with blepharitis for tear insufficiency or nasolacrimal drainage problems is appropriate because these can be associated with blepharitis and can often complicate management.

Histologic Findings

Seborrheic dermatitis is characterized histologically by spongiosis, mild perivascular, lymphohistiocytic, mononuclear cellular infiltrates in the superficial dermis. Staphylococcal blepharitis is a chronic nongranulomatous inflammation, usually with neutrophils and, often, acanthosis or parakeratosis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

A systematic and long-term commitment to a program of eyelid margin hygiene is the basis of treatment of blepharitis. Clinicians must ensure that patients recognize that the management of blepharitis is a process, which must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a process in which a patient goes from physician to physician, seeking some panacea for this frustrating condition.

• Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps.
• • First, application of heat to warm the eyelid gland secretions and to promote evacuation and cleansing of the secretory passages is essential. Patients commonly are directed to use soaked warm compresses and to apply them to the lids repeatedly. Warm water in a washcloth, soaked gauze pads, or microwaved, soaked cloths can be used. Patients should be instructed to use extreme care and to avoid the use of excessive heat.
  
  
  • Second, the eyelid margin is washed mechanically to remove adherent material, such as scurf, collarettes, and crusting, and to clean the gland orifices. This can be completed with a warm washcloth or with gauze pads. Water often is used, although some clinicians prefer that a few drops of baby shampoo be mixed in one bottle cap full of warm water to form a cleaning solution. Attention must be directed to gentle mechanical jostling or scrubbing of the eyelid margin itself, not the skin of the lids or of the bulbar conjunctival surface. Vigorous scrubbing is not necessary and may be harmful.
  
  
  • Third, an antibiotic ointment is applied to the eyelid margin after it has been soaked and scrubbed. Commonly used agents include erythromycin or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although their use is less appropriate for long-term management.


• Specific clinical situations may require additional treatment. Refractory cases of blepharitis often respond to oral antibiotic use. One- or two-month courses of tetracycline often are helpful in reducing symptoms in patients with more severe disease. Tetracycline is believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole is being studied.


• Tear film dysfunctions can prompt use of artificial tear solutions, tear ointments, and closure of the puncta. Associated conditions, such as herpes simplex, varicella-zoster, or staphylococcal skin disease, can require specific antimicrobial therapy based on culture. Seborrheic disease is often improved by the use of shampoos with selenium, although its use around the eyes is not recommended. Allergic dermatitis can respond to topical corticosteroid therapy.


• Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.


• Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation and may require referral to an oculoplastics surgeon.

Surgical Care

Surgical care for blepharitis is needed only for complications such as chalazion formation, trichiasis, ectropion, entropion, or corneal disease.

Consultations

Patients with refractory acne rosacea may benefit from a consultation with a dermatologist.

Diet

Patients with poor nutrition may be at a higher risk for blepharitis.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Useful medications in the treatment of blepharitis may include topical antibiotics, topical corticosteroids, and oral antibiotics. Typical blepharitis may be treated with a hygiene regimen and topical antibiotic ointment. Use of combination corticosteroid and antibiotic ointment should not be long term but may prove useful in reduction of inflammation in difficult cases. Oral tetracyclines may be required for refractory cases. Also, a combination antibiotic and steroid drop may be required for associated corneal disease.

Drug Category: Topical antibiotic ointments

Useful in targeting offending pathogens, usually Staphylococcus aureus (and possibly other Staphylococcus, Propionibacterium, Demodex, and Pityrosporum species, which chronically infect the lashes); the mechanism of action seems to be reduction of staphylococcal lipase production more than actual bacterial elimination.

Drug Category: Topical antibiotic/corticosteroid suspension/ointment

Topical corticosteroids, combined with an antibiotic, may be useful in the short-term treatment of blepharitis to decrease inflammation and more quickly diminish symptoms. Long-term use is not recommended. An ointment may be used for blepharitis, while a drop may be needed if associated corneal disease develops.

Drug Category: Oral antibiotics

Staphylococcal blepharitis usually responds more quickly to combined use of topical and oral antibiotics, although a trial of topical antibiotics alone usually is indicated before oral antibiotics should be considered. Tetracyclines are the DOC.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Patients with blepharitis usually are started on treatment, and they are seen in 2-6 weeks for a follow-up examination. During this visit, an assessment of the clinical response to therapy is made. The physician should again emphasize the necessity for a prolonged and dedicated course of treatment to the patient. Encouragement and support is critical in helping them to become committed to the course of treatment and to follow it. Additionally, the clinician is able to keep the focus on rigorous intervention by the patient, rather than accepting blame for not curing the condition.


• Patients are seen based on progress. If little improvement has been made after 1-2 months of treatment, intervention should be stepped up by prescribing antibiotic-corticosteroid ointments or oral antibiotics or by treating tear film dysfunction with such measures as punctal closure. Fluorescein staining is recommended on each examination.

Deterrence/Prevention

• Maintenance of a long-term regimen of lid hygiene helps prevent outbreaks of more symptomatic disease.

Complications

• Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.
• Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation.

Prognosis

• Overall, the prognosis for patients with blepharitis is good to excellent. Blepharitis only causes significant morbidity in an extremely small subset of patients. For most, it remains more of a symptomatic affliction than a true threat to their health and function. Patients experience a considerable amount of discomfort and misery that can greatly reduce their well-being and ability to carry out the daily activities of life and work. Recognition of the waxing and waning course of the disease, and of management through a prolonged program rather than via an instant cure, helps them to approach the disease in a successful manner.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Eyelid Inflammation (Blepharitis).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Patients with unilateral or very asymmetric blepharitis may have sebaceous cell carcinoma. An oculoplastics consult may be required for a lid biopsy.
• Certain systemic diseases, such as Sjogren syndrome or systemic lupus erythematosus, may present as blepharitis. Patients should be encouraged to have a complete physical examination with their primary care physician, and long-term follow-up care is indicated.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Arky R. Acromycin V tetracycline HCl. In: Physicians' Desk Reference. 53^rd ed. 1999:1514-1515. [Full Text].
• Cohen EJ. Cornea and external disease in the new millennium. Arch Ophthalmol. Jul 2000;118(7):979-81. [Medline].
• Diaz-Valle D, Benitez del Castillo JM, Fernandez Acenero MJ. Bilateral lid margin ulcers as the initial manifestation of Crohn disease. Am J Ophthalmol. Aug 2004;138(2):292-4. [Medline].
• Fraunfelder FT, Roy FH, Steinemann TL. Current Ocular Therapy. 5^th ed. 2000:72, 374, 378, 450.
• Held KS. Blepharitis. In: Decision Making in Ophthalmology. 2^nd ed. 2000:50-51.
• Kanski JJ. Marginal blepharitis. In: Clinical Ophthalmology. 1984:1.2-1.4.
• Roy FH. Ocular Differential Diagnosis. 7^th ed. 2002.
• Sullivan JH. Lids and lacrimal apparatus. In: General Ophthalmology. 14^th ed. 1995:78-81.
• Weisbecker CA, Fraunfelder FT, Rhee D. Physicians' Desk Reference for Ophthalmology. 28^th ed. 2000.
• Yanoff M, Fine BS. Inflammation. In: Ocular Pathology. 4^th ed. 1996:166-168.

Article Last Updated: Nov 21, 2006