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.