Adult Blepharitis Clinical Presentation

Updated: Dec 29, 2017
  • Author: R Scott Lowery, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Presentation

History

Patients with blepharitis typically present with symptoms of eye irritation, itching, erythema of the lids, flaking of the lid margins, and/or changes in the eyelashes.

Other 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
  • Visual fluctuations
  • Heat, cold, alcohol, and spicy-food intolerance

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, food and environmental intolerances, and eye irritation.

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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 of the cheeks and eyelid margins, 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), lid scarring and misdirection of lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid margin ulcers, plugging and "pouting" of the meibomian orifices, telangiectasias of the lid margin, and lid irregularity (tylosis).

The conjunctiva usually shows papillary injection. Advanced cases reveal tarsal thickening, loss of normal tarsal vascular architecture, subconjunctival substantia propria fibrosis, conjunctival scarring, and tarsal distortion due to cicatricial contraction and subsequent entropion.

Corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal ulcers, limbal inflammation and thickening (limbitis), peripheral corneal ectasia, 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 non-meibomian 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 an irregular 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 smooth tube of material that also surrounds the base of the lash as it intersects the lid. 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 is principally 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 lipid secretory material, inflamed orifices, and formation of hordeola and chalazia.

Various corneal changes can also result from posterior blepharitis.

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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 allergy, drug toxicity, or chemical reaction.

Sjogren syndrome may present as blepharitis.

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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. Complications of topical steroids such as cataract, glaucoma, and viral reactivations should be monitored.

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.

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