Blepharitis Diagnosis
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