Adult Blepharitis 

Updated: Jan 03, 2019
Author: R Scott Lowery, MD; Chief Editor: Andrew A Dahl, MD, FACS 

Overview

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 skin, eyelashes, and lash follicles, while the posterior variant involves the meibomian gland orifices, meibomian glands, tarsal plate, and blepharo-conjunctival junction. 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, atopy, and seborrheic dermatitis, as well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis, ectropion and entropion, infectious or other inflammatory conjunctivitis, and keratitis.

Pathophysiology

The pathophysiology of blepharitis frequently 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.

Epidemiology

Frequency

United States

Blepharitis is a common eye disorder in the United States and throughout the world. Based on Lemp et al’s estimate that 86% of all patients with dry eyes have concomitant blepharitis, more than 25 million Americans suffer from blepharitis.[1]

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, irregular astigmatism, 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.

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 with chronic blepharitis 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 the necessity 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 eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Eyelid Inflammation (Blepharitis).

 

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.

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 ulceration, 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.

Causes

Some specific causes of blepharitis may include the following:

  • Rosacea

  • Herpes simplex dermatitis

  • Varicella-zoster dermatitis

  • Molluscum contagiosum

  • Allergic or contact dermatitis

  • Seborrheic dermatitis

  • Staphylococcal dermatitis

  • Parasitic infections, such as Demodex and Phthiriasis palpebrarum[2, 3, 4]

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.

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.

 

DDx

 

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, digital-imaging techniques, conjunctival impression cytology, 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.

Imaging Studies

The LipiView (Tear Science) allows visualization of each individual meibomian gland in the everted inferior tarsal plate, permitting a semi-quantitative analysis of meibomian gland viability. This device can also measure incomplete blink rate and the thickness of the lipid oil tear layer in nanometers.

Similar images of the meibomian glands can also be obtained with the Keratograph 5M (Oculus).

 

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 not a cure but a process that must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a ceremony in which a patient goes from physician to physician, seeking some panacea for this frustrating condition.[5]

Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps, as follows:

  • First, application of heat to warm the eyelid gland secretions, to bring the turbid lipid glandular material to its melting point and resultant liquification, 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. Many useful eyelid applicators are readily available and provide a more sterile application surface. Patients should be instructed to use care 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 cotton-tip applicators or gauze pads. Tap water is often mistakenly used, rather than normal saline or boiled distilled water. Many clinicians instruct patients to mix a few drops of baby shampoo with warm water to form a cleaning solution. Several useful commercially available cleansing preparations are also available, including Ocusoft (generic), lavender scrubs (Oasis), and hypochlorous acid (Avenova). 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 bacitracin, polymyxin B, erythromycin, or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although, because of the risks associated with ocular steroids, 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 class agents often are helpful in reducing symptoms in patients with more severe disease and those with acne rosacea. Tetracycline, doxycycline, and minocycline are believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole and topical minocycline 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 or Elidel 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 oculoplastic surgeon to repair the lid abnormality.

Surgical Care

Surgical care for blepharitis is needed only for complications such as chalazion formation, trichiasis, ectropion, entropion, or corneal disease.

In addition, numerous new therapies are available, including the following:

Thermal pulsation therapy: the LipiFlow device (Tear Science) applies a homogenous temperature of 40.5 degrees C to both the anterior and posterior surface of the eyelids. Pulsations then mildly express the infected, inspissated and dead debris from the meibomian glands.

MiBoFlo is a thermal therapy applied to the outer lids in an office setting by a qualified technician.

BlephEx is a rotating light burr applied in office by a qualified technician that debrides the capped and inflamed meibomian orifice allowing for better flow of meibum and better results from other thermally based therapies, including home compresses.

The Maskin probe is a very fine stainless-steel tip applied to the thoroughly anesthetized inspissated meibomian gland orifice by an ophthalmologist. A very light electrical current is applied to facilitate the flow of meibum.

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.

Prevention

Maintenance of a long-term regimen of lid hygiene helps prevent outbreaks of more symptomatic disease.

Long-Term Monitoring

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 patients  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 or thermal pulsation. Fluorescein staining of the cornea is recommended on each examination.

 

Medication

Medication Summary

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 tetracycline class antibiotics may be required for refractory cases. Also, a combination antibiotic and steroid drop may be required for associated corneal disease.[6]

Ivermectin is a broad-spectrum antiparasitic drug used mainly to treat strongyloidiasis and onchocerciasis, although strong evidence upholds its off-label use against some arthropods. For patients with refractory blepharitis, ivermectin has been found to lessen the number of Demodex folliculorum found in the lashes.

In a noncomparative, interventional case series, researchers examined 24 eyes of 12 patients with refractory posterior blepharitis with the presence of D folliculorum in lash samples.[7] Patients were instructed to take 1 dose of oral ivermectin (200 ug/kg) and to repeat the treatment after 7 days. The researchers obtained tear meniscus height, Schirmer test results, noninvasive tear film break-up time, corneal fluorescein and rose bengal staining scores, and quantification of the absolute number of D folliculorum found in lashes from all patients 1 day before and 28 days after the 2-dose treatment.

A significant reduction was observed in the absolute number of D folliculorum found in the lashes after the treatment with oral ivermectin. Average values of Schirmer test results and tear film break-up time improved substantially after the treatment of oral ivermectin. The authors observed no significant improvement in average lacrimal meniscus height or value of corneal fluorescein and rose bengal staining after treatment with oral ivermectin.[7]

Topical antibiotic ointments

Class Summary

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 ophthalmic (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.

Bacitracin ophthalmic (Bacitracin Ophthalmic Ointment)

Bacitracin ointment is also 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. 

Topical antibiotic/corticosteroid suspension/ointment

Class Summary

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).

Oral antibiotics

Class Summary

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.

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.

Anthelminthics

Class Summary

For patients with refractory blepharitis, ivermectin has been used off-label to lessen the number of Demodex folliculorum found in the lashes. Ivermectin is a broad-spectrum antiparasitic drug.

Ivermectin (Stromectol)

Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Off-label use has been described for blepharitis associated with Demodex folliculorum.

Dermatology, Herbals

Tea tree oil (Australian tea tree oil, Cymeme, Melaleuca alternifolia)

Tea tree oil provides a direct ant-parasitic effect upon D folliculorum. Tea tree oil, the essential oil derived from the native plant Melaleuca alternifolia, is characterized by 15 major components. Scientific studies have shown that 4-Terpineol, or Terpinen-4-ol (T4O), is the most important ingredient in tea tree oil. Tea tree oil is available commercially and from numerous natural-remedy companies. The active ingredient is available through BioTissue (Cliradex).

 

Questions & Answers

Overview

What is adult blepharitis?

What is the difference between anterior and posterior blepharitis?

Which systemic diseases are associated with adult blepharitis?

What is the pathophysiology of adult blepharitis?

What is the prevalence of adult blepharitis in the US?

What is the morbidity associated with adult blepharitis?

What are the racial predilections of adult blepharitis?

How does the prevalence of adult blepharitis vary by sex?

How does the prevalence of adult blepharitis vary by age?

What is the prognosis of adult blepharitis?

Where can patient education resources be found for adult blepharitis?

Presentation

What are the signs and symptoms of adult blepharitis?

Which history is characteristic of adult blepharitis?

What is the typical disease course for adult blepharitis?

Which external exam findings are characteristic of adult blepharitis?

Which gross exam findings are characteristic of adult blepharitis?

Which slit-lamp exam findings are characteristic of adult blepharitis?

Which conjunctival findings are characteristic of adult blepharitis?

Which corneal findings are characteristic of adult blepharitis?

Which physical findings are characteristic of the anterior variant of adult blepharitis?

Which disease is most common with the staphylococcal variant of anterior blepharitis?

Which findings are characteristic of the posterior variant of adult blepharitis?

Which systemic diseases cause adult blepharitis?

What causes chronic adult blepharitis?

What causes acute adult blepharitis?

Which syndrome may present as adult blepharitis?

What are the possible complications of adult blepharitis?

DDX

What are the differential diagnoses for Adult Blepharitis?

Workup

What is the role of lab studies in the workup of adult blepharitis?

Which histologic are characteristic of adult blepharitis?

What is the role of the LipiView (Tear Science) imaging study in the workup of adult blepharitis?

What is the role of the Keratograph 5M (Oculus) imaging study in the workup of adult blepharitis?

Treatment

What is the basis of medical treatment for adult blepharitis?

What are the steps in eyelid hygiene for the treatment of adult blepharitis?

When are additional treatments indicated for adult blepharitis?

What is the role of surgery in the treatment of adult blepharitis?

What are the surgical options for adult blepharitis?

When is consultation with a dermatologist indicated in the treatment of adult blepharitis?

How does diet affect adult blepharitis?

How is adult blepharitis prevented?

What is included in long-term monitoring of adult blepharitis?

What are the treatment options for adult blepharitis that is unresponsive after 1-2 months of treatment?

Medications

Which medications are used in the treatment of adult blepharitis?

What is the role of ivermectin in the treatment of adult blepharitis?

What is the efficacy of ivermectin in the treatment of adult blepharitis?

Which medications in the drug class Dermatology, Herbals are used in the treatment of Adult Blepharitis?

Which medications in the drug class Anthelminthics are used in the treatment of Adult Blepharitis?

Which medications in the drug class Oral antibiotics are used in the treatment of Adult Blepharitis?

Which medications in the drug class Topical antibiotic/corticosteroid suspension/ointment are used in the treatment of Adult Blepharitis?

Which medications in the drug class Topical antibiotic ointments are used in the treatment of Adult Blepharitis?