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Blepharitis

Definition
Blepharitis is an inflammatory condition of the eyelid margins involving the skin, eyelashes, and meibomian glands.
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Pathophysiology
The pathophysiology of blepharitis can be categorized based on the anatomical location of the disease: anterior and posterior blepharitis. Anterior blepharitis is often associated with seborrheic dermatitis or staphylococcal infection, while posterior blepharitis is linked to meibomian gland dysfunction.
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Epidemiology
The prevalence of blepharitis in ophthalmological and optometric practice is reported at 37% and 47%, respectively.
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Disease course
Clinically, blepharitis presents with ocular symptoms such as burning sensation, irritation, tearing, and red eyes. Visual problems such as photophobia and blurred vision may also occur. In some cases, complications like dry eye syndrome or chalazion can develop.
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Prognosis and risk of recurrence
The prognosis of blepharitis is generally good with proper management. Although it is a chronic condition, symptoms can be effectively controlled with appropriate treatment and lifestyle modifications.
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Key sources
The following summarized guidelines for the evaluation and management of blepharitis are prepared by our editorial team based on guidelines from the College of Optometrists (CO 2023), the American Academy of Ophthalmology (AAO 2022; 2019), and the British Association of Dermatologists (BAD 2021).
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Guidelines

1.Screening and diagnosis

Differential diagnosis
As per AAO 2022 guidelines:
Suspect an eyelid tumor in patients with atypical eyelid margin inflammation or disease not responding to medical treatment and obtain a careful re-evaluation in these patients.
Refer patients with an inflammatory eyelid lesion appearing suspicious for malignancy to an appropriate specialist.
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2.Diagnostic investigations

History and physical examination
Elicit initial history, including the following:
Situation
Guidance
Ocular symptoms and signs
Redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, blurring or fluctuating vision, contact lens intolerance, photophobia, increased frequency of blinking, and recurrent hordeolum
Chronology of symptoms
Time of day when symptoms are worse, duration of symptoms
Laterality of symptoms
Unilateral versus bilateral presentation
Exacerbating conditions
Smoke, allergens, wind, contact lenses, low humidity, retinoids, diet, alcohol consumption, and eye makeup
Symptoms related to systemic diseases
Rosacea, atopy, psoriasis, and GvHD
Current and previous systemic and topical medications
Antihistamines or drugs with anticholinergic effects, or drugs used in the past that might have an effect on the ocular surface, such as isotretinoin
Recent exposure to an infected individual
Patient with pediculosis palpebrarum
Ocular history
Previous intraocular and eyelid surgery, local trauma, including mechanical, thermal, chemical, and radiation injury, history of cosmetic blepharoplasty, history of styes and/or chalazia
Perform initial physical examination, including assessment of visual acuity, external examination of the skin and eyelids, and slit-lamp biomicroscopy (including tear film, anterior eyelid margin, eyelashes, posterior eyelid margin, tarsal conjunctiva, bulbar conjunctiva, and cornea).

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  • Conjunctival culture

3.Diagnostic procedures

Eyelid biopsy: consider performing an eyelid biopsy to exclude the possibility of carcinoma in patients with marked asymmetry, resistance to treatment, or unifocal recurrent chalazia not responding well to treatment. Consult a pathologist before performing the biopsy if sebaceous cell carcinoma is suspected.

4.Medical management

Topical antibiotics: as per CO 2023 guidelines, consider offering topical antibiotics in patients with staphylococcal or seborrhoeic blepharitis not controlled by first-line management:
antibiotic ointment (such as chloramphenicol) BID; place in eyes or rub into lid margin with fingertip
short course of topical azithromycin (off-label use).
C

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  • Topical corticosteroids

  • Oral antibiotics

5.Nonpharmacologic interventions

Eyelid cleansing: as per CO 2023 guidelines, advise eyelid cleansing measures to wipe away bacteria and deposits from eyelid margins and to improve signs and symptoms in patients with blepharitis.
B

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  • Warm compresses

6.Therapeutic procedures

Intense pulsed light therapy: insufficient evidence to recommend intense pulsed light therapy for the management of meibomian gland dysfunction.
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7.Specific circumstances

Patients with Demodex blepharitis
Suspect Demodex blepharitis in patients with characteristic cylindrical dandruff at the roots of eyelashes or refractory blepharitis.
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Insufficient evidence to support the use of tea tree oil in patients with Demodex blepharitis. Use lower concentrations to avoid ocular toxicity when using tea tree oil.
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8.Patient education

General counseling: as per AAO 2022 guidelines, counsel patients about the chronicity and recurrence of the disease process and that symptoms can frequently be improved but are rarely eliminated.

9.Follow-up and surveillance

Follow-up: arrange follow-up visits to elicit interval history, measure visual acuity, perform external physical examinations, and obtain slit-lamp biomicroscopy.