Blepharitis Diagnosis

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

• 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

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

• 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 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