Blepharitis

Introduction

Blepharitis is an inflammatory condition that affects the eye lid margins. The edges of the eyelids become red and swollen.¹ It is a chronic condition which means that symptoms will reoccur if they are not managed. It may occur intermittently, and it is usually bilateral (meaning it affects both eyes).

TFOS DEWS II classify blepharitis according to its anatomical location; either anterior, (that is the portion of the eyelid in front of the mucocutaneous junction), or posterior (the portion behind the mucocutaneous junction).²

Blepharitis is the most common reason for same day cancellation of elective cataract surgery.³ In research it has been linked with post operative endophthalmitis in cataract surgery where it was reported that the genetic makeup of organisms from the vitreous matched those recovered from the patient’s eyelids.⁴

Anterior blepharitis therefore affects the base of the eyelashes, the eyelash follicles and/or the eyelid skin and can be further categorised as marginal blepharitis where the inflammation is involving the lash follicles and blepharo-dermatitis when the eyelid skin is involved.

Posterior blepharitis affects the meibomian glands and gland orifices and has a range of potential aetiologies, the primary cause being meibomian gland dysfunction (MGD)⁵ Both anterior and posterior blepharitis can coexist and have links to dry eye disease sharing similar clinical features.^2,6The focus of the rest of this article will be on anterior blepharitis.

Anterior blepharitis can be either:

Seborrheic – this is a disorder of the ciliary sebaceous glands of Zeis which is associated with dandruff leading to waxy scales on the eyelashes.
Bacterial – this is caused by bacteria normally staphylococcal by either (1) direct infection (2) reaction to staphylococcal exotoxins or (3) allergic response to staphylococcal antigens, and causes hard crusting on the eyelashes. It is less common than seborrheic.

Demodex infestation has also been found to be associated with blepharitis. Demodex are microscopic (ectoparasite) mites that live on the surface of the human body. Two types are thought to be specific to humans, Demodex folliculorum DF (which is longer and more commonly localised to the face) and Demodex brevis DB (which are shorter and more commonly found on the neck and chest). DF are found in eyelash follicles and DB burrow deep into sebaceous and meibomian glands. Demodex mites are also present in healthy eye lids without signs of blepharitis.⁷

Reports suggest that demodex act as carriers of bacteria such as staphylococcus⁷ and that the infestation and waste of the mites causes blockage of the follicles and glands and/or an inflammatory response.⁵ The number of demodex mites is believed to increase with age, and over 50% of patients with demodex will have signs of blepharitis.⁸ Treatment is needed when it becomes necessary to reduce the quantity of DB and DF and this has been shown to improve patient symptoms and ocular surface health.⁸

Clinical Evaluation

Risk Factors for Blepharitis

Seborrheic dermatitis
Infections
Rosacea
Allergies
Demodex
Dry eyes
Long-term contact lens wear
Cosmetics

Signs

Bacterial (staphylococcal) anterior blepharitis

Lash crusting (scales at base of lashes)
Inflamed lid margins
Lid margin redness
Misdirection of lashes
Loss of lashes (madarosis)
Telangiectasia
Recurrent styes
Conjunctival redness
Secondary signs may include
- Corneal punctate erosions inferiorly
- Marginal keratitis

Seborrhoeic anterior blepharitis

Oily or greasy deposits on lid margins and around lash bases
Inflamed lid margins
Lid margin redness
Conjunctival redness

Demodex blepharitis

Crusting of lashes with a clear sleeve around the base of the lash extending upwards on the lash
Lid margin redness
Inflamed lid margins
Persistent infestation may cause
- Lash misalignment
- Trichiasis
- Loss of lashes (madarosis)

Differences between common types of anterior blepharitis

	Staphylococcal Blepharitis	Seborrhoeic blepharitis	Demodex blepharitis
Lashes	Lash crusting (scales at base of lashes)	Oily/greasy deposits on lid margins and around lash bases	Crusting of lashes with a clear sleeve around the base of the lash extending upwards on the lash
	Loss of lashes (madarosis)	Lash loss rare	Lash loss can occur
	Misdirection of lashes	–	–
Lid margin	Lid margin redness	Lid margin redness	Lid margin redness
	Eventual scarring and thickening of lid margin	Flaky skin in eyebrows	Mites under high magnification may be visible
	Telangiectasia	–	–
Inflammation	Significant inflammation on lid margins	Less inflammation on lid margins	Minimal inflammation on lid margins
Conjunctiva	Conjunctival redness	Conjunctival redness	–
Age of patient	Typically seen in younger patients	Tends to be in older patients	Prevalence increases with age
Skin signs	Skin is usually clear	Associated seborrhoeic dermatitis – flaky red skin	Rosacea association – red skin, telangiectasia papules and pustules

Symptoms

Varying degrees of ocular discomfort and or symptoms are reported but patients may also be asymptomatic. Symptoms when present may include:

Discomfort
Soreness
Burning
Itching
Dry eye symptoms
Transient blurring of vision
Contact lens intolerance

Investigations

Full anterior segment examination to exclude any other potential lid pathology
Consider appearance of lid crusting to aid differential diagnosis
Meibomian gland assessment (some practitioners find it useful to express the glands to gauge the quality and quantity of the secretions)

Management & Advice

The management of blepharitis depends on the type and severity of blepharitis.¹⁰ The key to treating most types of blepharitis is keeping the lids clean and free of crusts. The following provides guidance on the treatment options.

Non-Pharmacological

Lid & lash cleansing: There are a variety of lid cleansing products available to clean the crusting and debris from the lid margins and lash follicles. These products have been designed specifically for the delicate eye area. Traditionally diluted baby shampoo has been recommended for lid hygiene, but it is now known that baby shampoo can cause irritation and inflammation of the ocular surface along with adding to tear film instability.⁹ There are also products available that target demodex in addition to cleansing the eye lids and lashes.
Lid warming can be used prior to cleansing to soften and loosen any crusting on the lashes prior and may be particularly beneficial if the crusting is marked. It will also be beneficial for patients with MGD to soften thickened meibum. Commercially available warm compresses are often used for this purpose.
Hydration/Lubrication: As dry eye is commonly present as a consequence of blepharitis patients are often recommended to include an eye lubricant as part of the management of their blepharitis. Lubricants should be instilled after the lid warming and cleansing.

Pharmacological

For more persistent or difficult to treat cases pharmacological options that may be considered include:¹⁰

Topical antibiotics or topical antibiotic steroid combinations that can be applied to the lid margins
Oral drugs of the tetracycline family or other systemic antibiotics (e.g. Oxytetracycline, doxycycline, minocycline, lymecycline, and Azithromycin)

For Demodicosis treatments include

Ivermectin is an antiparasitic drug and can be used orally or topically
Metronidazole is an antibiotic and antiparasitic drug

This article serves as an overview of the condition and treatment options. It does not serve as a clinical guidance. Eyecare provider guidelines should be used when managing patients.