blepharitis
BLEPHARITIS
Blepharitis is an inflammation process affecting the eyelid margins, eyelash follicles or openings of the anteriorly-placed accessory lacrimal glands and the posteriorly-placed Meibomian glands that causes ocular irritation and redness acutely but usually chronically.
It may have periods of exacerbations and remissions.
It usually occurs in middle-aged adults but can also start in childhood.
Can affect vision by disrupting the surface of the cornea and the bulbar conjunctiva; may influence tear film composition.

Diagnosis

  • Based on history & characteristic findings in comprehensive medical eye evaluation

History

  • Common signs & symptoms:
    • Redness, irritation, burning, tearing, pruritus, itching, crusting, loss of eyelashes, eyelid sticking, photophobia, frequent eye blinking
    • Usually has an overlap of symptoms seen in the types of blepharitis 
  • Time of day when symptoms are worse & its duration helps to identify the specific type of blepharitis
  • Aggravating factors: Smoke, allergens, wind, contact lens, eye makeup, low humidity, retinoids, diet, alcohol consumption
  • Associated diseases: Allergy, rosacea, herpes zoster ophthalmicus
  • Predisposing factors:
    • Drugs (eg antihistamines, drugs that may affect the ocular surface or w/ anticholinergic effects)
    • Recent exposure to an infected individual (eg pediculosis palpebrarum)
    • Previous intraocular & eyelid surgery
    • Local trauma (eg mechanical, thermal, chemical, radiation injury)
    • History of cosmetic blepharoplasty, styes &/or chalazion

Physical Examination

Eye & Adnexa exam

  • Visual acuity for baseline status
  • External examination shows:
    • Facial & scalp skin: Seborrheic dermatitis (itching & flaking); Rosacea (facial flushing, telangiectasia, red or swollen nose)
    • Eyelids: Crusting of the lashes or lid margins, edges appear pink or irritated, presence of ectropion or entropion due to chronic inflammation
    • Eyelashes: Chronic inflammation may present as trichiasis (misdirection), madarosis (loss), poliosis (pigmentation loss), or distichiasis (abnormal growth from meibomian gland orifices), abnormal deposits at the base
    • Eye asymmetry that shows severity of inflammation
    • Presence of chalazion, hordeolum or scarring
  • Slit-lamp biomicroscopy helps in differentiating anterior & posterior blepharitis (see next page for specific characteristic)
    • Eyelids: Chronic inflammation leads to lid margin ulceration, neovascularization & dilated blood vessels, lid skin thickening, lid contour irregularity; Pediculosis palpebrarum in the anterior eyelid margin
    • Conjunctiva: Diffuse conjunctival injection
    • Tear film: Foamy appearance, presence of debris, increased tear break up time & evaporation rate
    • Cornea: Inflamed lid margins that cross the cornea at the 2, 4, 8 & 10 o’clock positions, punctate epithelial erosions in the inferior third, marginal corneal infiltrates, corneal nodules called phlyctenules near the limbus
    • Check for tear meniscus, quality of mucus & lipid, foamy discharge & debris in the tear film

Ancillary Tests

  • Aids in diagnosis
  • Eyelid margin cultures
    • For patients w/ recurrent anterior blepharitis w/ severe inflammation &
    • For those who are unresponsive to treatment
  • Epilated eyelashes microscopic exam
    • May reveal Demodex mites which are found in patients w/ chronic blepharoconjunctivitis
    • Shows polymorphonuclear leukocytes & gram-positive cocci
  • Eyelid biopsy
    • To rule out possible cancer in cases of marked asymmetry, refractory to treatment or unifocal recurrent chalazia that is unresponsive to therapy

Classification

  • Classification is based on location & subcategories based on etiology that will guide in the proper treatment to be given
  • In some patients, a combination of the types of blepharitis exist

Anterior Blepharitis

  • Inflammation of the anterior eyelid margin especially the base & follicles of the eyelashes

Staphylococcal blepharitis

  • Commonly caused by Staphylococcus epidermidis & Staphylococcus aureus
  • More prevalent in warmer climates & in middle-aged women who have no other skin problems
  • Produces a moderately acute inflammation of short duration
  • Clinical features:
    • Foreign body sensation, irritation, itching & mild sticking of the eyelids in the early stages
    • Scaling, crusting & redness of the eyelid margin w/ collarette formation at the base of the cilia
    • Frequent loss of eyelashes & misdirection
    • Eyelid ulceration w/ severe exacerbations
    • Eyelid scarring & hordeolum may occur
    • Mild to moderate conjunctival injection & phlyctenules may occur
    • Frequent aqueous tear deficiency
    • Corneal involvement especially in the lower third of the cornea eg punctate epithelial erosions, neovascularization, & marginal infiltrates
    • Thickened lid margins, trichiasis, lid-margin notching, madarosis, ectropion or entropion if the condition becomes chronic
  • Associated conditions: Keratoconjunctivitis sicca, Isotretinoin use

Seborrheic/Squamous blepharitis

  • Commonly caused by seborrheic dermatitis of the scalp & eyebrows
  • More common in men & in older individuals
  • Usually chronic w/ periods of exacerbation & remission
  • Clinical features:
    • Burning, stinging, itching & ocular irritation or discomfort
    • Lids may be hyperemic at the anterior margin
    • Eyelid deposits that are oily or greasy w/ foamy scales called scurf
    • Mild conjunctival injection
    • Frequent aqueous tear deficiency
    • Cornea has inferior punctate epithelial erosions

Posterior Blepharitis

  • Inflammation of the meibomian glands & gland orifices

Meibomian gland dysfunction

  • Usually caused by irregular oil production by the glands of the eyelids which creates a favorable environment for bacterial growth
  • Clinical features:
    • Eyelash misdirection & scarring may occur w/ long-standing disease
    • Excess lipid, foamy discharge eyelid deposits
    • Chalazia is occasional to frequent, sometimes multiple
    • Mild to moderate conjunctival injection w/ papillary reaction to tarsal conjunctiva
    • Frequent evaporative dry eye as measured by shortened tear break-up time
    • Cornea has inferior punctate epithelial erosions, fine infiltrates superiorly & inferiorly, scarring, neovascularization & pannus, ulceration
    • Pouting or plugging of meibomian orifices
    • Turbid fluid to cheese-like material meibomian secretions 
  • Associated w/ ocular rosacea, hormone (androgen) dysfunction or contact lens intolerance
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