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
Editor's Recommendations
Most Read Articles
Jairia Dela Cruz, 04 Jul 2016
The risk of band keratopathy may be greatly increased in patients with end-stage renal disease (ESRD), and significant risk factors are iridocyclitis and degenerated eye, according to a Taiwan-based cohort study billed as the largest to ever be conducted on the relationship between the two conditions.
Audrey Abella, 26 Apr 2017
Intravitreous administration of the vascular endothelial growth factor (VEGF) inhibitor ranibizumab does not increase the risk of cardiovascular and cerebrovascular events in patients with diabetic macular edema (DME), according to a recent study.
4 days ago
A number of clinical tumour and treatment parameters, most of which are shown to reflect initial tumour size, appear to contribute to the regression of choroidal melanoma after brachytherapy, a recent study has shown.
Tristan Manalac, 01 May 2018
Eating dark chocolates may have short-term beneficial impacts on vision, according to a recent study, which reports significant improvements in contrast sensitivity and visual acuity following dark vs milk chocolate consumption.