Blepharitis Diagnosis
Diagnosis
- Based on history and characteristic findings in comprehensive medical eye evaluation
History
- Common signs and 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 and 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 with anticholinergic effects)
- Recent exposure to an infected individual (eg pediculosis palpebrarum)
- Previous intraocular and eyelid surgery
- Local trauma (eg mechanical, thermal, chemical, radiation injury)
- History of cosmetic blepharoplasty, styes and/or chalazion
Physical Examination
Eye and Adnexa Exam
- Visual acuity for baseline status
- External examination shows:
- Facial and scalp skin: Seborrheic dermatitis (itching and 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 and posterior blepharitis
- Eyelids: Chronic inflammation leads to lid margin ulceration, neovascularization and 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 and evaporation rate
- Cornea: Inflamed lid margins that cross the cornea at the 2, 4, 8 and 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 and lipid, foamy discharge and debris in the tear film
Ancillary Tests
- Eyelid margin cultures
- For patients with recurrent anterior blepharitis with severe inflammation and
- For those who are unresponsive to treatment
- Epilated eyelashes microscopic exam
- May reveal Demodex mites which are found in patients with chronic blepharoconjunctivitis
- Shows polymorphonuclear leukocytes and 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 and 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 and follicles of the eyelashes
Staphylococcal Blepharitis
- Commonly caused by Staphylococcus epidermidis and Staphylococcus aureus
- More prevalent in warmer climates and 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 and mild sticking of the eyelids in the early stages
- Scaling, crusting and redness of the eyelid margin with collarette formation at the base of the cilia
- Frequent loss of eyelashes and misdirection
- Eyelid ulceration with severe exacerbations
- Eyelid scarring and hordeolum may occur
- Mild to moderate conjunctival injection and phlyctenules may occur
- Frequent aqueous tear deficiency
- Corneal involvement especially in the lower third of the cornea eg punctate epithelial erosions, neovascularization and pannus, scarring, thinning, phlyctenules, and 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 and eyebrows
- More common in men and in older individuals
- Usually chronic with periods of exacerbation and remission
- Clinical features:
- Burning, stinging, itching and ocular irritation or discomfort
- Lids may be hyperemic at the anterior margin
- Eyelid deposits that are oily or greasy with foamy scales called scurf
- Mild conjunctival injection
- Frequent aqueous tear deficiency
- Cornea has inferior punctate epithelial erosions
Posterior Blepharitis
- Inflammation of the meibomian glands and gland orifices
Meibomian Gland Dysfunction (MGD)
- Chronic, diffuse abnormality of the meibomian glands, usually characterized by terminal duct obstruction and/or qualitative/quantitative changes in glandular secretion
- Subcategories include hypersecretory, hyposecretory and obstructive forms
- Usually caused by irregular oil production by the glands of the eyelids which creates a favorable environment for bacterial growth
- May occur in the absence of inflammation
- Usually occurs in older patients with longer history of ocular symptoms
- Most common cause of evaporative dry eye disease
- Clinical features:
- Eyelash misdirection and scarring may occur with long-standing disease
- Excess lipid, foamy discharge eyelid deposits
- Chalazia is occasional to frequent, sometimes multiple
- Mild to moderate conjunctival injection with 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 and inferiorly, scarring, neovascularization and pannus, ulceration
- Pouting or plugging of meibomian orifices
- Turbid fluid to cheese-like material meibomian secretions
- Associated with ocular rosacea, hormone (androgen) dysfunction or contact lens intolerance