Blepharitis

Background

• Blepharitis is a common eye disorder characterized by a chronic inflammatory process primarily involving the skin, lashes, and meibomian glands of the eyelid.
• Blepharitis is classified as:
  • Anterior blepharitis affects the anterior lid margin and eyelashes and is usually infectious (bacterial, viral, or parasitic) or seborrheic (encrustation of lid margin and blockage of gland orifices) in etiology.
  • Posterior blepharitis affects the meibomian glands and is usually due to dysfunction or structural changes of the meibomian glands (meibomian gland dysfunction).
  • Marginal blepharitis is the co-occurrence of both anterior and posterior blepharitis.
• Dry eye, giant papillary conjunctivitis (GPC), rosacea, and exacerbating factors such as the use of contact lenses, smoke, allergens, low humidity, retinoids, diet, alcohol consumption, and eye makeup are risk factors for blepharitis.
• Blepharitis can occur on its own or with other conditions associated with eyelid inflammation (such as, ocular rosacea).

Evaluation

• Blepharitis is usually diagnosed clinically in patients with typical findings on history and physical examination.
  • Common symptoms in patients with blepharitis include:
    • sore eyelids
    • irritated eyes
    • itchy, burning, or gritty eyes
    • red eyes
    • dry or watery eyes
    • increased frequency of blinking
    • foreign body sensation
    • photophobia
    • contact lens intolerance
    • eyelids sticking together (especially in the morning)
  • Blepharitis should also be suspected in patients with recurrent conjunctivitis, keratitis, neovascularization, eyelid inflammation, hordeolae, chalazia, and/or bilateral chronic and recurrent ocular symptoms (Strong Recommendation).
• The initial evaluation of a patient with symptoms and signs suggestive of blepharitis should include relevant aspects of a comprehensive medical eye evaluation (Strong Recommendation). General findings may include:
  • scurf (greasy scales)
  • telangiectatic vascular changes of eyelid margin
  • thickened secretions of meibomian glands
  • conjunctival hyperemia
  • punctuate keratopathy
  • cornea vascularization and ulceration
• There are no specific diagnostic tests available for blepharitis but ancillary testing which may be helpful in diagnostically challenging cases includes:
  • conjunctival and/or eyelid margin cultures
  • microscopic evaluation of epilated eyelashes to assess for Demodex mites
  • eyelid biopsy to rule out cancer in patients with marked asymmetry, resistance to therapy, or unifocal recurrent chalazia that do not respond well to therapy
  • confocal microscopy to identify periglandular inflammatory cells
• Consider the possibility of carcinoma in patients with chronic blepharitis unresponsive to therapy, particularly if it is associated with loss of the eyelashes (Strong Recommendation).

Management

• Eyelid cleansing with commercially available lid scrubs is recommended as the first-line treatment for all patients with blepharitis, regardless of type (Strong Recommendation).
• In patients with symptoms refractory to eyelid hygiene, consider topical ophthalmic medications including topical ophthalmic antibiotic ointments and/or short-term topical ophthalmic corticosteroids (Weak Recommendation).
• If corticosteroid therapy is prescribed, reevaluate patients within a few weeks to evaluate the response to therapy, intraocular pressure, and treatment compliance (Strong Recommendation).
• In patients with blepharitis and a coexisting aqueous tear deficiency, consider cyclosporine and/or punctal plugs (Weak Recommendation).
• Consider systemic antibiotics, such as oral tetracyclines (Weak Recommendation), in patients with:
  • blepharitis unresponsive to topical ophthalmic medications
  • secondary infections of meibomian glands
• Consider weekly 50% tea tree oil eyelid scrubs and daily tea tree oil shampoo scrubs for ≥ 6 weeks in Demodex infections (Weak Recommendation).
• Use of a multidisciplinary approach with a dermatologist, an allergist, or an oculoplastics specialist can be helpful (Strong Recommendation).
• Explain to patients that blepharitis is typically a chronic condition without a permanent cure, and that successful management depends on the patient compliance with a treatment regimen (Strong Recommendation).