eMedicine Specialties > Ophthalmology > Lid
Blepharitis, Adult
Updated: Jul 30, 2009
Introduction
Background
Blepharitis refers to a family of inflammatory disease processes of the eyelid(s).
Blepharitis can be divided anatomically into anterior and posterior blepharitis. Anterior blepharitis refers to inflammation mainly centered around the eyelashes and follicles, while the posterior variant involves the meibomian gland orifices. Anterior blepharitis usually is subdivided further into staphylococcal and seborrheic variants.
Frequently, a considerable overlap exists in these processes in individual patients. Blepharitis often is associated with systemic diseases, such as rosacea and seborrheic dermatitis, as well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis, conjunctivitis, and keratitis.
Pathophysiology
The pathophysiology of blepharitis usually involves bacterial colonization of the eyelids. This results in direct microbial invasion of tissues, immune system–mediated damage, or damage caused by the production of bacterial toxins, waste products, and enzymes. Colonization of the lid margin is increased in the presence of seborrheic dermatitis or meibomian gland dysfunction.
Frequency
United States
Blepharitis is a common eye disorder in the United States and throughout the world.
Mortality/Morbidity
The exact association between blepharitis and mortality is not known, but diseases with known mortality, such as systemic lupus erythematosus, may have blepharitis as part of their constellation of findings. Associated morbidity includes loss of visual function, well-being, and ability to carry out daily life activities. The disease process can result in damage to the lids with trichiasis, notching entropion, and ectropion. Corneal damage can result in inflammation, scarring, loss of surface smoothness, and loss of optical clarity. If severe inflammation develops, corneal perforation can occur.
Race
No known studies demonstrate racial differences in the incidence of blepharitis. Rosacea may be more common in fair-skinned individuals, although this finding may be only because it is more easily and frequently diagnosed in these individuals.
Sex
No well-designed studies of differences in the incidence and clinical features of blepharitis between the sexes have been found.
Age
Seborrheic blepharitis is more common in an older age group. The apparent mean age is 50 years.
Clinical
History
Patients with blepharitis typically present with symptoms of eye irritation, itching, erythema of the lids, and/or changes in the eyelashes.
- Common complaints include the following:
- Burning
- Watering
- Foreign body sensation
- Crusting and mattering of the lashes and medial canthus
- Red lids
- Red eyes
- Photophobia
- Pain
- Decreased vision
- The condition most typically has a chronic course with intermittent exacerbations and eruptions of symptomatic disease. Seborrheic dermatitis can be associated with symptoms of scalp itching, flaking, and oily skin. Rosacea can be associated with a red and swollen nose (rhinophyma), facial flushing, broken and distended vessels in the face, pustules, oily skin, and eye irritation.
Physical
- External examination of patients with blepharitis often demonstrates findings of associated conditions. Herpetic skin disease can be associated with erythema and vesicle formation. Seborrheic dermatitis is typified by oily skin and flaking from the scalp or brows. Rosacea is associated with pustules, rhinophyma, telangiectasias, erythema, and pustules.
- Gross examination of the eyelids shows erythema and crusting of the lashes and lid margins.
- Slit lamp examination shows additional features, including loss of lashes (madarosis), whitening of the lashes (poliosis), scarring and misdirection of lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid margin ulcers, plugging and "pouting" of the meibomian orifices, telangiectasias, and lid irregularity (tylosis).
- The conjunctiva usually shows papillary injection.
- Corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal ulcers, pannus, and phlyctenule formation. Corneal involvement occurs most commonly at the positions where the limbus is crossed by the upper and lower lid margins, at the 2-, 4-, 8-, and 10-o'clock positions. Corneal infiltrates can progress to infection and even perforation.
- The anterior variant of blepharitis involves mainly the lashes and associated oil glands. Various formations of debris adhere to the lashes.
- Crusting refers to flakes of material that adhere to the lashes and usually represents seborrheic disease. The epithelial material is often referred to as scurf.
- A collarette is a ringlike formation around the lash shaft that occurs with staphylococcal disease. Staphylococcal blepharitis is typified by the formation of collarettes on the lashes.
- A sleeve is a tube of material that also surrounds the lash. Sleeving is associated with infection by the eyelash parasite, Demodex.
- Ulcers form at the base of the lashes. They are covered by a crust of fibrin, which is lifted up as the lash shaft grows.
- Seborrheic blepharitis also involves primarily the anterior lid and is associated with the formation of greasy crusts of material, which are adherent to the eyelash shaft.
- Corneal disease is most common with the staphylococcal variant of anterior lid disease.
- Posterior blepharitis mainly is related to dysfunction of the meibomian glands. Alterations in secretory metabolism and function lead to disease. The meibomian secretions become more waxlike and begin to block the gland orifices. The stagnant material becomes a growth medium for bacteria and can seep into the deeper eyelid tissue layers, causing inflammation. These processes lead to gland plugging, inspissated material, inflamed orifices, and formation of chalazia.
- Various corneal changes can also result from posterior blepharitis.
Causes
- Some specific causes of blepharitis may include the following:
- Chronic blepharitis has been associated with exposure to chemical fumes, smoke, smog, and other irritants.
- Acute blepharitis is most commonly due to allergic drug or chemical reaction.
- Sjogren syndrome may present as blepharitis.
Differential Diagnoses
| Basal Cell Carcinoma, Eyelid | Hordeolum |
| Cellulitis, Preseptal | Keratitis, Bacterial |
| Chalazion | Keratoconjunctivitis, Atopic |
| Conjunctivitis, Bacterial | Keratoconjunctivitis, Epidemic |
| Conjunctivitis, Viral | Keratoconjunctivitis, Sicca |
| Contact Lens Complications | Keratoconjunctivitis, Superior Limbic |
| Dermatitis, Contact | Ocular Rosacea |
| Dry Eye Syndrome | Trichiasis |
Other Problems to Be Considered
Seborrheic dermatitis
Herpetic eye disease
Parasitic infections, such as Demodex or Phthiriasis palpebrarum1,2,3
Workup
Laboratory Studies
- In general, diagnostic tests do not typically need to be performed for suspected blepharitis. Research and other rare protocols may involve eyelid margin cultures, transillumination studies of the meibomian glands, marginal biopsies, or even analysis of gland secretions.
- Testing patients with blepharitis for tear insufficiency or nasolacrimal drainage problems is appropriate because these can be associated with blepharitis and can often complicate management.
Histologic Findings
Seborrheic dermatitis is characterized histologically by spongiosis, mild perivascular, lymphohistiocytic, mononuclear cellular infiltrates in the superficial dermis. Staphylococcal blepharitis is a chronic nongranulomatous inflammation, usually with neutrophils and, often, acanthosis or parakeratosis.
Treatment
Medical Care
A systematic and long-term commitment to a program of eyelid margin hygiene is the basis of treatment of blepharitis. Clinicians must ensure that patients recognize that the management of blepharitis is a process, which must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a process in which a patient goes from physician to physician, seeking some panacea for this frustrating condition.4
- Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps.
- First, application of heat to warm the eyelid gland secretions and to promote evacuation and cleansing of the secretory passages is essential. Patients commonly are directed to use soaked warm compresses and to apply them to the lids repeatedly. Warm water in a washcloth, soaked gauze pads, or microwaved, soaked cloths can be used. Patients should be instructed to use extreme care and to avoid the use of excessive heat.
- Second, the eyelid margin is washed mechanically to remove adherent material, such as scurf, collarettes, and crusting, and to clean the gland orifices. This can be completed with a warm washcloth or with gauze pads. Water often is used, although some clinicians prefer that a few drops of baby shampoo be mixed in one bottle cap full of warm water to form a cleaning solution. Attention must be directed to gentle mechanical jostling or scrubbing of the eyelid margin itself, not the skin of the lids or of the bulbar conjunctival surface. Vigorous scrubbing is not necessary and may be harmful.
- Third, an antibiotic ointment is applied to the eyelid margin after it has been soaked and scrubbed. Commonly used agents include erythromycin or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although their use is less appropriate for long-term management.
- Specific clinical situations may require additional treatment. Refractory cases of blepharitis often respond to oral antibiotic use. One- or two-month courses of tetracycline often are helpful in reducing symptoms in patients with more severe disease. Tetracycline is believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole is being studied.
- Tear film dysfunctions can prompt use of artificial tear solutions, tear ointments, and closure of the puncta. Associated conditions, such as herpes simplex, varicella-zoster, or staphylococcal skin disease, can require specific antimicrobial therapy based on culture. Seborrheic disease is often improved by the use of shampoos with selenium, although its use around the eyes is not recommended. Allergic dermatitis can respond to topical corticosteroid therapy.
- Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.
- Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation and may require referral to an oculoplastics surgeon.
Surgical Care
Surgical care for blepharitis is needed only for complications such as chalazion formation, trichiasis, ectropion, entropion, or corneal disease.
Consultations
Patients with refractory acne rosacea may benefit from a consultation with a dermatologist.
Diet
Patients with poor nutrition may be at a higher risk for blepharitis.
Medication
Useful medications in the treatment of blepharitis may include topical antibiotics, topical corticosteroids, and oral antibiotics. Typical blepharitis may be treated with a hygiene regimen and topical antibiotic ointment. Use of combination corticosteroid and antibiotic ointment should not be long term but may prove useful in reduction of inflammation in difficult cases. Oral tetracyclines may be required for refractory cases. Also, a combination antibiotic and steroid drop may be required for associated corneal disease.5
Topical antibiotic ointments
Useful in targeting offending pathogens, usually Staphylococcus aureus (and possibly other Staphylococcus, Propionibacterium, Demodex, and Pityrosporum species, which chronically infect the lashes); the mechanism of action seems to be reduction of staphylococcal lipase production more than actual bacterial elimination.
Erythromycin ointment 0.5% (E-Mycin)
Erythromycin ointment is applied to lid margins with a clean vector, such as a cotton swab or a clean fingertip, after crusting and debris have been removed with gentle cleansing or scrubbing.
Dosing
Adult
Apply a small amount (0.5-inch ribbon) topically to the outer lid 3-4 times qd
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity to erythromycin or ointment additives
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)
Topical antibiotic/corticosteroid suspension/ointment
Topical corticosteroids, combined with an antibiotic, may be useful in the short-term treatment of blepharitis to decrease inflammation and more quickly diminish symptoms. Long-term use is not recommended. An ointment may be used for blepharitis, while a drop may be needed if associated corneal disease develops.
Sulfacetamide sodium and prednisolone acetate (Blephamide)
Sulfacetamide is an antibiotic that, like erythromycin, has been shown to be effective against staphylococci. The combined corticosteroid is useful in decreasing inflammation and decreasing symptoms. Use of the 2 agents combined has been shown to increase patient compliance. Blephamide is available in an ophthalmic suspension and in an ointment, both containing the same concentrations of active ingredients (10% sulfacetamide/0.2% prednisolone).
Dosing
Adult
Ointment: 0.5-inch ribbon topically to affected lid(s) 3-4 times qd and once or twice at night; discontinuation should be gradual
Drops: May be instilled 1 gtt 3-4 times qd; gradual discontinuation is necessary
Pediatric
Not established
Interactions
Decreases effects of silver compounds and gentamicin
Contraindications
Documented hypersensitivity to any ingredients, sulfonamides, or corticosteroids; viral, mycobacterial, and fungal eye disease; glaucoma or ocular hypertension
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use may cause glaucoma and posterior subcapsular cataract formation; rarely, fatalities have occurred due to severe reactions to sulfonamides, including Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, or other blood dyscrasias; if inflammation or pain persists longer than 48 h or becomes aggravated, the patient should discontinue and consult a physician; consult a Physicians' Desk Reference or package insert for further details
Oral antibiotics
Staphylococcal blepharitis usually responds more quickly to combined use of topical and oral antibiotics, although a trial of topical antibiotics alone usually is indicated before oral antibiotics should be considered. Tetracyclines are the DOC.
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Metabolized by the liver and the kidneys. Usually not the DOC for most staphylococcal infections but has been shown to be effective in the treatment of refractory blepharitis, in which Staphylococcus aureus is the usual pathogen. Tetracyclines should not be taken with antacids or foods, but rather, they should be taken 1-2 h after meals.
Dosing
Adult
1-2 g PO divided bid to qid, depending on severity, for 1-2 mo
Pediatric
Not established
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Contraindications
Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Has been shown to cause yellow-gray-brown discoloration of the teeth if used during tooth development (last one half of pregnancy up to age 8 y); photosensitivity is common and avoidance of the sun is essential; may cause an increase in BUN and should be avoided in those with impaired renal function; has been linked to the development of pseudotumor cerebri; superinfection may occur; various adverse reactions may occur; refer to the Physicians' Desk Reference or package insert for more complete information
Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Dosing
Adult
100-200 mg PO qd; some sources recommend using one half of initial dose during second month
Pediatric
Not established
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Contraindications
Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Follow-up
Further Outpatient Care
- Patients with blepharitis usually are started on treatment, and they are seen in 2-6 weeks for a follow-up examination. During this visit, an assessment of the clinical response to therapy is made. The physician should again emphasize the necessity for a prolonged and dedicated course of treatment to the patient. Encouragement and support is critical in helping them to become committed to the course of treatment and to follow it. Additionally, the clinician is able to keep the focus on rigorous intervention by the patient, rather than accepting blame for not curing the condition.
- Patients are seen based on progress. If little improvement has been made after 1-2 months of treatment, intervention should be stepped up by prescribing antibiotic-corticosteroid ointments or oral antibiotics or by treating tear film dysfunction with such measures as punctal closure. Fluorescein staining is recommended on each examination.
Deterrence/Prevention
- Maintenance of a long-term regimen of lid hygiene helps prevent outbreaks of more symptomatic disease.
Complications
- Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.
- Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation.
Prognosis
- Overall, the prognosis for patients with blepharitis is good to excellent. Blepharitis only causes significant morbidity in an extremely small subset of patients. For most, it remains more of a symptomatic affliction than a true threat to their health and function. Patients experience a considerable amount of discomfort and misery that can greatly reduce their well-being and ability to carry out the daily activities of life and work. Recognition of the waxing and waning course of the disease, and of management through a prolonged program rather than via an instant cure, helps them to approach the disease in a successful manner.
Patient Education
- For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Eyelid Inflammation (Blepharitis).
Miscellaneous
Medicolegal Pitfalls
- Patients with unilateral or very asymmetric blepharitis may have sebaceous cell carcinoma. An oculoplastics consult may be required for a lid biopsy.
- Certain systemic diseases, such as Sjogren syndrome or systemic lupus erythematosus, may present as blepharitis. Patients should be encouraged to have a complete physical examination with their primary care physician, and long-term follow-up care is indicated.
References
Pinckney J 2nd, Cole P, Vadapalli SP, Rosen T. Phthiriasis palpebrarum: a common culprit with uncommon presentation. Dermatol Online J. Apr 15 2008;14(4):7. [Medline].
Divani S, Barpakis K, Kapsalas D. Chronic blepharitis caused by Demodex folliculorum mites. Cytopathology. Mar 7 2009;[Medline].
Dhingra KK, Saroha V, Gupta P, Khurana N. Demodex-associated dermatologic conditions - A coincidence or an etiological correlate. Review with a report of a rare case of sebaceous adenoma. Pathol Res Pract. Jan 22 2009;[Medline].
Jackson WB. Blepharitis: current strategies for diagnosis and management. Can J Ophthalmol. Apr 2008;43(2):170-9. [Medline].
Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther. Sep 2008;25(9):858-70. [Medline].
Arky R. Acromycin V tetracycline HCl. In: Physicians' Desk Reference. 53rd ed. 1999:1514-1515. [Full Text].
Cohen EJ. Cornea and external disease in the new millennium. Arch Ophthalmol. Jul 2000;118(7):979-81. [Medline].
Diaz-Valle D, Benitez del Castillo JM, Fernandez Acenero MJ. Bilateral lid margin ulcers as the initial manifestation of Crohn disease. Am J Ophthalmol. Aug 2004;138(2):292-4. [Medline].
Fraunfelder FT, Roy FH, Steinemann TL. Current Ocular Therapy. 5th ed. 2000:72, 374, 378, 450.
Held KS. Blepharitis. In: Decision Making in Ophthalmology. 2nd ed. 2000:50-51.
Kanski JJ. Marginal blepharitis. In: Clinical Ophthalmology. 1984:1.2-1.4.
Roy FH. Ocular Differential Diagnosis. 7th ed. 2002.
Sullivan JH. Lids and lacrimal apparatus. In: General Ophthalmology. 14th ed. 1995:78-81.
Weisbecker CA, Fraunfelder FT, Rhee D. Physicians' Desk Reference for Ophthalmology. 28th ed. 2000.
Yanoff M, Fine BS. Inflammation. In: Ocular Pathology. 4th ed. 1996:166-168.
Keywords
adult blepharitis, seborrheic blepharitis, eyelid inflammation, inflammation of the eyelid, bacterial colonization of the eyelid, bacterial infection, anterior blepharitis, posterior blepharitis
Contributor Information and Disclosures
Author
R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's Hospital
R Scott Lowery, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
Medical Editor
Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.
Pharmacy Editor
Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.
Managing Editor
Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching
CME Editor
Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
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