Blepharitis, Pediatric

Inflammatory or infectious process of the eyelid margin, typically involving skin, lashes, and meibomian glands

Associated with itchiness, redness, flaking, and crusting of the eyelids

Usually chronic, intermittent with exacerbations and remissions

Typically bilateral

No universal classification system

Historically classified according to location, anterior versus posterior

Anterior blepharitis: affects the base of the eyelashes and eyelash follicles

Posterior blepharitis: affects the meibomian glands

Can also be classified by etiology

Inflammatory: seborrheic, meibomian gland dysfunction, allergic, associated with rosacea

Infectious: bacterial (most commonly Staphylococcusaureus or Staphylococcusepidermidis), viral, fungal, or parasitic

Epidemiology

One of the most common ocular disorders

Presents in patients of all ages

Mean age of presentation is age 50 years.

No gender differences seen.

Risk Factors

Presence of atopic, allergic, or seborrheic dermatitis

Rosacea

Tear deficiency and dysfunction

Contact lens use

Isotretinoin used to treat severe cystic acne

Less common risk factors include underlying immunologic disorders such as lupus, eyelid tumors, trauma, and other dermatoses.

Pathophysiology

Complex and results from the interplay between abnormal lid margin secretions, lid margin organisms, and dysfunction of the tear film

Infectious blepharitis: Bacteria such as Staphylococcus may cause direct infection of the eyelids, evoke reaction to the exotoxin, or provoke an allergic reaction to the staphylococcal antigens.

Inflammatory blepharitis: Inflammation of the meibomian glands leads to impaired gland secretions and instability of the tear film.

This condition can have a direct toxic effect and promote bacterial overgrowth.

Commonly Associated Conditions

Seborrheic dermatitis

Allergic or contact dermatitis

Down syndrome (trisomy 21)

Ocular rosacea

Dry eye (keratoconjunctivitis sicca)

Hordeolum

Chalazion

Diagnosis

Signs and Symptoms

Redness of eyelid margin

Irritation

Burning

Tearing

Gritty sensation

Dry or watery eyes

Increased blinking

Loss of eyelashes

Photophobia

Contact lens intolerance

Eye discharge or crust, particularly along lashes

Eyelid sticking, especially in the morning

History

Duration of symptoms: Blepharitis is often chronic, with periods of exacerbation and remission.

Symptoms and signs of systemic disease

Current and previous systemic and topical medications (in particular: antihistamines, drugs with anticholinergic effects, and isotretinoin

Contact lens use

Exacerbating conditions such as eye makeup use, smoke, allergens

Previous intraocular or eyelid surgery

Trauma

Past medical and family histories of atopy

Recent exposure to lice

Physical Exam

Use a focused direct light source to carefully evaluate the eyelids for abnormal eyelid position, eyelash loss, hyperemia of the eyelid margins, abnormal deposits at the base of the eyelids, ulceration, vesicles, scaling, chalazion/hordeolums, and scarring.

Examine the conjunctiva and sclera to look for signs of inflammation, which warrants a slit-lamp examination.

Assess visual acuity.

Perform a general exam looking for signs of systemic disease such as seborrhea, atopic dermatitis, rosacea, and lupus.

Diagnostic Tests & Interpretation

Lab

Diagnosis is made clinically. There are no specific diagnostic tests to confirm the diagnosis of blepharitis.

In refractory cases or cases of recurrent anterior blepharitis with severe inflammation, cultures of the eyelid margins may be useful.

Differential Diagnosis

Acute conjunctivitis (bacteria, viral, or allergic)

Atopic or contact dermatitis

Keratitis

Iritis

Glaucoma

Chemical burn

Corneal abrasion

Foreign body

Hordeolum

Chalazion

Lice

Trichotillomania

Treatment

General Measures

Several treatments may be helpful and are generally used in combination.

Treatments may provide symptomatic relief but usually do not result in cure for chronic cases.

Treatments include the following:

Warm compresses

Eyelid hygiene

Antibiotics (topical and/or systemic)

Topical short course anti-inflammatory agents

Warm compresses should be applied for 15 minutes at least twice daily to loosen crusts.

Eyelid hygiene

Consists of massaging the eyelid margins daily and carefully removing the crusts using cotton swabs, cotton balls, commercial eyelid scrubs, and/or diluted baby shampoo

Children should be instructed to avoid rubbing their eyes if possible and to wash hands frequently.

Wearing contact lens or eye makeup should be avoided during exacerbations.

Activities that result in decreased blinking can dry out the eye and worsen exacerbations. Such activities may include television watching and use of computers or video games.

Medication

Warm compresses and eyelid hygiene are the traditional mainstay of therapy.

Medications can be added in conjunction with conservative measures.

A topical antibiotic ophthalmic ointment (such as bacitracin or erythromycin) may be applied 1-4 times daily until inflammation resolves.

A brief course of topical corticosteroids are generally reserved for severe inflammation and in cases of severe conjunctival injection or marginal keratitis.

The minimal effective dose of corticosteroid should be used and for as short a time as possible.

Long-term use of oral antibiotics (such as erythromycin or tetracyclines) may be useful in severe cases.

Issues for Referral

Moderate or severe pain

Vision loss

Severe or chronic redness

Corneal involvement

Traumatic eye injury

Recent ocular surgery

Distorted pupil

Recurrent episodes

More severe eyelid inflammation with nodular mass, ulceration, or extensive scarring

Lack of improvement with conservative measures and topical antibiotics

Ongoing Care

No additional care is needed if symptoms resolve completely.

Patients should be educated about the potential for recurrence and chronicity with blepharitis.

Warm compresses and eyelid hygiene treatment may be required long term.

Additional Reading

American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern ®; Guidelines. Blepharitis: Limited Revision. San Francisco, CA: American Academy of Ophthalmology; 2011. http://www.aao.org/ppp. Accessed July 17, 2013.

H01.001 Unspecified blepharitis right upper eyelid

H01.002 Unspecified blepharitis right lower eyelid

H01.005 Unspecified blepharitis left lower eyelid

H01.003 Unspecified blepharitis right eye, unspecified eyelid

H01.006 Unspecified blepharitis left eye, unspecified eyelid

H01.004 Unspecified blepharitis left upper eyelid

SNOMED

41446000 Blepharitis (disorder)

91662004 Ulcerative blepharitis

231797007 Seborrheic blepharitis

278808000 Staphylococcal blepharitis

FAQ

Q: Is blepharitis contagious?

A: Blepharitis is not contagious. However, if blepharitis is due in part to bacterial infection, the bacteria can be transmitted to other family members and result in conjunctivitis. Thus, good hand hygiene is important.

Q: Will the child outgrow this?

A: Although some children may be cured, for many, blepharitis is a chronic condition in which symptomatic control is the goal.

Q: Is blepharitis common in children?

A: Although blepharitis can occur in patients of all ages, it tends to be seen much more frequently in adults.