Blepharitis

BASICS

DESCRIPTION

Common, usually chronic, inflammatory reaction of the eyelid margin
Commonly presents as irritation, burning, redness, flaking, and crusting of the eyelids worse in morning
Defined as anterior or posterior blepharitis with considerable overlap
- Anterior blepharitis:
  - Staphylococcal
    - Seborrheic
- Posterior blepharitis:
  - Meibomian gland dysfunction (MGD)
Areas affected: cornea, eyelid
Can be primary or secondary to a systemic disease

EPIDEMIOLOGY

Incidence

Very common
All ethnic groups (Asians > Caucasians)
Predominant age:
- Nonstaphylococcal (average age: 50)
- Staphylococcal (average age: <42)
Predominant sex:
- Nonstaphylococcal: male = female
- Staphylococcal: male < female

RISK FACTORS

Seborrheic dermatitis
Contact dermatitis
Herpes simplex dermatitis
Varicella-zoster dermatitis
Acne rosacea
Immunocompromised state (e.g., AIDS, chemotherapy)
Isotretinoin use
Dry eye syndrome
Demodex folliculorum infestation
Giant papillary conjunctivitis

ETIOLOGY

Seborrheic
- Anterior eyelid inflammation secondary to increased and abnormal meibomian gland secretions
- Eyelid erythema, crusting, and oily appearance
- Can be associated with keratitis presenting as punctate epithelial erosions
- Associated with acne rosacea
Staphylococcal
- Infection of the glands of the eyelid margin
- Commonly caused by Staphylococcus aureus and coagulase-negative Staphylococcus, with occasional concomitant Moraxella lacunata infection
- Crusting (golden) around eyelashes that is worse in the morning, collarette formation around lashes, scaling, crusting, and erythema
- Severe cases are associated with keratitis and eyelid ulceration.
Meibomian gland dysfunction: chronic obstruction and inflammation of the meibomian glands; associated with acne rosacea, acne vulgaris, and oral retinoid therapy
Other types of blepharitis:
- Contact dermatitis/blepharitis:
  - Develops from type IV hypersensitivity; common causes include ocular medications, topical anesthetics, antivirals, and cosmetics.
  - May occur with secondary Staphylococcus infection
- Eczematoid blepharitis
  - Caused by type I hypersensitivity reaction to exotoxins and antigens from local flora
  - Strong association with eczema and asthma
  - Staphylococcal infection common
- Parasitic blepharitis
  - Cylindrical sleeves along lashes
  - Found in 30% of chronic blepharitis

PATHOPHYSIOLOGY

The exact etiopathogenesis is unknown.
Suspected to be multifactorial
- Chronic low-grade infections of the ocular surface with bacteria
- Infestations with certain parasites such as the mite Demodex
- Inflammatory skin conditions such as atopy and seborrhea

COMMONLY ASSOCIATED CONDITIONS

See "Risk Factors"¯ and "Differential Diagnosis."¯

DIAGNOSIS

HISTORY

Duration of symptoms
Unilateral or bilateral presentation
Note any exacerbating conditions (e.g., smoke, allergens, wind, contact lenses).
Pertinent past medical history: rosacea, herpetic zoster, autoimmune disease
Current and recent medication use
Recent exposure to infected individuals
Frequently reported in all types of blepharitis
- Burning
- Itching
- Eyelid erythema
- Conjunctival infection (red eyes)
- Lacrimation, tearing
- Tear deficiency
- Foreign body sensation
- Photophobia (light sensitivity)
- Impaired vision

PHYSICAL EXAM

Test of visual acuity
External exam (skin and eyelids)
- Staphylococcal
  - Recurrent stye (external or internal hordeolum)
  - Missing, broken, or misdirected eyelashes (trichiasis)
  - Eyelid deposits: matted, hard scales; collarettes (ring-like formation around the lash shaft)
  - Ulcerations at base of eyelashes (rare)
  - Eyelid scarring may occur.
- Seborrheic blepharitis
  - Eyelid deposits: dry flakes; oily or greasy secretions on lid margins and/or lashes
  - Associated dandruff of scalp and eyebrows
- Meibomian gland dysfunction
  - Eyelash misdirection may occur with long-standing disease.
  - Eyelid deposits: fatty deposits; may be foamy
  - Eyelid margin thickening
  - Plugged meibomian gland orifices
    - No expression of fluid upon gentle pressure of lid
  - Chalazion (sometimes multiple)
  - Eyelid scarring (notching) with long-term disease
  - Association with ocular rosacea
- Mixed blepharitis: Signs and symptoms of >1 type of blepharitis may be present.

DIFFERENTIAL DIAGNOSIS

Masquerade syndrome (1)
- Persistent inflammation and thickening of eyelid margin may indicate squamous cell, basal cell, or sebaceous cell carcinoma masquerading as blepharitis. These carcinomas also may mimic styes or chalazia.
Impetigo/erysipelas
Herpetic zoster ophthalmicus
Viral infections
Contact or atopic dermatitis
Medicamentosa

DIAGNOSTIC TESTS & INTERPRETATION

Follow-Up Tests & Special Considerations

Consider masquerade syndrome in all cases of recurrent, persistent, or atypical chalazion; chronic unilateral unresponsive blepharoconjunctivitis; diffuse or nodular tumors of the eyelid; orbital mass developing after removal of an eyelid or caruncular tumor; and any tumor developing in a person with a history of ocular radiotherapy.
Cultures in atypical blepharitis
Biopsy in atypical cases for carcinoma
Slit-lamp biomicroscopy
- Examine tear film, eyelid margins, eyelashes, tarsal and bulbar conjunctiva, and cornea.
- Fluorescein eye stain to evaluate for punctate epithelial keratitis
- Inspect for loss of lashes (madarosis), whitening of the lashes (poliosis), trichiasis, crusting, eyelid margin ulcers, and lid irregularities.

TREATMENT

GENERAL MEASURES

Promote proper eyelid hygiene (2,3)[C].
- Apply warm compresses for several minutes at least once a day to soften adherent encrustations.
- The eyelid margins then are scrubbed gently with eyelid cleanser or diluted baby shampoo twice a day to remove adherent material and clean the meibomian gland orifices (4)[C].
Gentle vertical massage of the eyelids can help to express meibomian secretions in patients with meibomian gland dysfunction (2)[C].
Discontinue soft contact lenses use during an acute case of blepharitis (3)[B].

MEDICATION

First Line

According to Cochrane 2012, topical antibiotics provided some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and PO antibiotics, was inconclusive (5)[A].
No strong evidence supports any of the treatments in terms of curing chronic blepharitis (5)[A].
Topical treatment to lid, if Staphylococcus likely:
- Bacitracin ointment: 500 Ī¼g/g or (second choice)
- Erythromycin: 0.5% ophthalmic ointment
  - The frequency and duration of treatment are guided by the severity (2)[C].
  - Topical corticosteroids (short term) should be used cautiously and briefly if at all and only for severe eyelid or ocular surface inflammation. The minimum effective dose and duration should be used; long-term use should be avoided if possible (6)[C].
For patients with meibomian gland dysfunction inadequately controlled with eyelid hygiene, consider doxycycline 100 mg/day or tetracycline 1,000 mg/day in divided doses, tapered after clinical improvement (2 to 4 weeks) to doxycycline 50 mg/day or tetracycline 250 to 500 mg/day (2)[C].
Oral azithromycin (500 mg/day for 3 days in three cycles with 7-day intervals) has been used successfully in the management of blepharitis associated with acne rosacea as an alternative to oral tetracyclines (2)[C].
Because aqueous tear deficiency is common in blepharitis, use twice-daily artificial tears in addition to eyelid hygiene and medications.
Contraindications: Allergy to medication; tetracyclines are not for use in pregnancy, nursing women, or children <8 years of age.
Precautions
- Tetracyclines can cause photosensitization, gastrointestinal upset, vaginitis, and rarely, azotemia. Tetracyclines have been implicated in cases of pseudotumor cerebri, and their metabolism may alter the effectiveness of certain medications (2).
- Corticosteroids may increase intraocular pressure and risk of cataract.
- Oral azithromycin can cause problems in patients with heart disease as it may cause irregular heart rhythms (2).

Second Line
Topical fluoroquinolones (e.g., gatifloxacin 0.3%, levofloxacin 0.5%, or moxifloxacin 0.5%) may be helpful for persistent or recurrent staphylococcal blepharitis or for those patients who prefer a solution.

ISSUES FOR REFERRAL

Chronic recurrent blepharitis requires referral to an ophthalmologist for evaluation whether patient should continue soft lens use.
A patient with chronic blepharitis that does not respond to therapy, particularly if associated with loss of eyelashes or corneal changes.

ADDITIONAL THERAPIES

Various commercial products are marketed to consumers and prescribed to patients; however, there is no substantial evidence of effectiveness (5)[A].

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Patients should schedule a return visit if their condition worsens despite treatment.
Return visit intervals for patients with severe disease vary.
If corticosteroid is prescribed, reevaluate within a few weeks to measure intraocular pressure and determine response to therapy.

PATIENT EDUCATION

"Blepharitis Fact Sheet"¯ from the American Academy of Ophthalmology
Advise patient that blepharitis is a chronic condition likely to recur if eyelid hygiene is not maintained after antibiotic treatment is discontinued.

PROGNOSIS

Blepharitis cannot be permanently cured, and successful management is dependent on patient compliance with treatment regimen.

COMPLICATIONS

Stye and chalazion
Scarring of eyelid margin
Corneal infection
Superficial keratopathy
Corneal neovascularization and ulceration
Ectropion/entropion

REFERENCES

11 Tsai T, O'Brien JM. Masquerade syndromes: malignancies mimicking inflammation in the eye. Int Ophthalmol Clin. 2002;42(1):115-131.22 American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines: Blepharitis. San Francisco, CA: American Academy of Ophthalmology; 2013.33 Eyelid hygiene for blepharitis. Insight. 2011;36(1):24.44 McCulley JP, Shine WE. Changing concepts in the diagnosis and management of blepharitis. Cornea. 2000;19(5):650-658.55 Lindsley K, Matsumura S, Hatef E, et al. Interventions for chronic blepharitis. Cochrane Database Syst Rev. 2012;(5):CD005556.66 Abelson MB, Cohane K, Fink K. Blepharitis: hiding in plain sight. Rev Ophthalmol. 2004;11(5):106-109.

CODES

ICD10

H01.009 Unspecified blepharitis unspecified eye, unspecified eyelid
H01.019 Ulcerative blepharitis unspecified eye, unspecified eyelid
L21.8 Other seborrheic dermatitis
H01.029 Squamous blepharitis unspecified eye, unspecified eyelid
H01.002 Unspecified blepharitis right lower eyelid
H01.006 Unspecified blepharitis left eye, unspecified eyelid
B02.39 Other herpes zoster eye disease
H01.026 Squamous blepharitis left eye, unspecified eyelid
H01.005 Unspecified blepharitis left lower eyelid
H01.001 Unspecified blepharitis right upper eyelid
H01.023 Squamous blepharitis right eye, unspecified eyelid
H01.003 Unspecified blepharitis right eye, unspecified eyelid
H01.004 Unspecified blepharitis left upper eyelid

ICD9

373.00 Blepharitis, unspecified
373.01 Ulcerative blepharitis
690.18 Other seborrheic dermatitis
373.02 Squamous blepharitis

SNOMED

41446000 Blepharitis (disorder)
91662004 Ulcerative blepharitis
231797007 Seborrheic blepharitis
58912008 Squamous blepharitis (disorder)
15631131000119108 Bilateral blepharitis (disorder)
278808000 Staphylococcal blepharitis
1099121000119108 Blepharitis of upper and lower eyelids of bilateral eyes (disorder)

CLINICAL PEARLS

Blepharitis is often a chronic condition; symptoms frequently can be lessened but rarely are eliminated.
Promote proper eyelid hygiene.
Bacitracin or erythromycin ophthalmic ointment is the first-line treatment if Staphylococcus is suspected.

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