BLEPHARITIS

BLEPHARITIS - Joshua J. Spooner, PharmD, MS; A. Raquel Matteo-Bibeau, MD
BASICS
DESCRIPTION
• An inflammatory reaction of the eyelid margin
- Usually occurs as seborrheic or as staphylococcal blepharitis.
- Multiple types may coexist.
• System(s) Affected: Skin/Exocrine
• Synonym(s): Granulated eyelids
EPIDEMIOLOGY
• Predominant age: Adult
• Predominant sex: Male = Female
Incidence
One of the most common ocular disorders
RISK FACTORS
• Seborrheic dermatitis
• Contact dermatitis
• Herpes simplex dermatitis
• Varicella-zoster dermatitis
• Acne rosacea
• Diabetes mellitus
• Immunocompromised state (e.g., AIDS, chemotherapy)
• Isotretinoin use
• Dry eye syndromes
ETIOLOGY
• Seborrheic
- Accelerated shedding of skin cells with associated sebaceous gland dysfunction
- Malassezia furfur (formerly Pityrosporum ovale) yeasts often colonize
• Staphylococcal
- Superinfection of Zeis glands of lid margin and meibomian glands posterior to lashes with Staphylococcus aureus
- Usually part of mixed blepharitis
• Meibomian gland dysfunction
- Obstruction and inflammation of the meibomian glands
 Associated with acne rosacea, acne vulgaris, and oral retinoid therapy
• Other types of blepharitis
- Ulcerative blepharitis
 More severe blepharitis with small marginal ulceration and destruction of the hair follicles
- Contact dermatitis/blepharitis
 Develops from type IV hypersensitivity; common causes include ocular medications, topical anesthetics, antivirals, and cosmetics
 May occur with secondary Staphylococcus infection
- Eczematoid blepharitis
 Caused by hypersensitivity reaction to exotoxins and antigens from local flora
 Strong association with eczema, asthma
 Staphylococcal infection common
- Angular blepharitis
 Often caused by Staphylococcus or Moraxella infection
ASSOCIATED CONDITIONS
See "Risk Factors"


DIAGNOSIS
SIGNS AND SYMPTOMS (1)[c]
• Frequently reported in all types of blepharitis
- Burning
- Itching
- Eyelid erythema
- Conjunctival injection (red eyes)
- Lacrimation, tearing
- Tear deficiency
- Foreign body sensation
- Photophobia (light sensitivity)
- Impaired vision
• Staphylococcal
- Recurrent stye (external or internal hordeolum)
- Missing, broken, or, misdirected eyelashes (trichiasis)
- Eyelid deposits: Matted, hard scales; collarettes (ringlike formation around the lash shaft)
- Ulcerations at base of eyelashes (rare)
- Eyelid scarring may occur
• Seborrheic blepharitis
- Eyelid deposits: Dry flakes, oily or greasy secretions on lid margins and/or lashes
- Associated dandruff of scalp, eyebrows
• Meibomian gland dysfunction
- Eyelash misdirection may occur with longstanding disease
- Eyelid deposits: Fatty deposits; may be foamy
- Eyelid margin thickening
- Plugged meibomian gland orifices
- Chalazion (sometimes multiple)
- Eyelid scarring with long-term disease
• Mixed blepharitis
- Signs and symptoms of more than 1 type of blepharitis may be present
History
• Duration of symptoms (1)[C]
• Unilateral or bilateral presentation (1)[C]
• Note any exacerbating conditions (e.g., smoke, allergens, wind, contact lenses, etc.) (1)[C]
• Symptoms related to systemic diseases (1)[C]
• Current and recent medication use (1)[C]
• Recent exposure to infected individuals (1)[C]
Physical Exam
• Test of visual acuity (1)[C]
• External examination (skin and eyelids) (1)[C]
TESTS
Lab
Special tests
• Cultures in atypical blepharitis
• Biopsy in atypical cases for carcinoma
Imaging
Slit-lamp biomicroscopy (1)[C]
• Examine tear film, eyelid margins, eyelashes, tarsal and bulbar conjunctiva, and cornea:
- Reveals loss of lashes (madarosis), whitening of the lashes (poliosis), trichiasis, crusting, eyelid margin ulcers, and lid irregularities
DIFFERENTIAL DIAGNOSIS
• Masquerade syndrome:
- Persistent inflammation and thickening of eyelid margin may indicate squamous cell, basal cell, or sebaceous cell carcinoma masquerading as blepharitis.
 These carcinomas may also mimic styes or chalazia.
- Sebaceous carcinoma of the eyelid has a 22% fatality rate. Up to 1/2 of these potentially fatal sebaceous cell carcinomas may resemble benign inflammatory diseases, particularly chalazia and chronic blepharoconjunctivitis.
- Consider this in all cases of recurrent, persistent, or atypical chalazion; chronic unilateral unresponsive blepharoconjunctivitis; diffuse or nodular tumors of the eyelid; orbital mass developing after removal of an eyelid or caruncular tumor; and any tumor developing in a person with a history of ocular radiotherapy (2)[C].
TREATMENT
Best evidence treatment
• American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice patterns Committee. Preferred Practice Pattern: Blepharitis. San Francisco: AAO. 2003.
GENERAL MEASURES
• Appropriate health care: Outpatient
• Promote proper eyelid hygiene (1)[C]
- Apply warm compresses for several minutes once daily to soften adherent encrustations
- The eyelid margins are then gently scrubbed with eyelid cleanser or diluted baby shampoo twice a day, to remove adherent material and clean the meibomian gland orifices (3)[C]
• Brief, gentle massage of the eyelids can help express meibomian secretions in patients with meibomian gland dysfunction (1)[C]
• Discontinue soft contact lenses use during an acute case of blepharitis.
- Chronic recurrent blepharitis requires referral to ophthalmologist for evaluation as to whether patient should continue in lenses.
MEDICATION (DRUGS)
First Line
• Topical treatment to lid, if Staphylococcus likely: Follow eye hygiene with application of bacitracin 500 u/g or (second choice) erythromycin 0.5% ophthalmic ointment:
- Apply with a cotton-tipped applicator
- The frequency and duration of treatment guided by the severity (1)[C].
• Topical corticosteroids (short-term) may be useful for eyelid or ocular surface inflammation.
- The minimum effective dose should be used; long-term use avoided if possible (1,4)[C]
• For patients with meibomian gland dysfunction inadequately controlled with eyelid hygiene, consider: Doxycycline 100 mg/d or tetracycline 1000 mg/d in divided doses, tapered after clinical improvement (2-4 weeks) to doxycycline 50 mg/d or tetracycline 250-500 mg/d (1)[C].
• As aqueous tear deficiency is common in blepharitis, use twice-daily artificial tears in addition to eyelid hygiene and medications.
• Contraindications: Allergy to medication; tetracyclines are not for use in pregnancy, nursing women, or in children 8 years.
• Precautions: Tetracyclines may cause photosensitivity; sunscreen recommended. Corticosteroids may increase intraocular pressure and risk of cataract.
• Significant possible interactions: Tetracyclines; avoid concurrent administration with antacids, dairy products, or iron. May potentiate the effect of warfarin. Broad-spectrum antibiotics may reduce the effectiveness of oral contraceptives; barrier method recommended.
Second Line
• Topical fluoroquinolones (gatifloxacin 0.3%, levofloxacin 0.5%, or moxifloxacin 0.5%) may be helpful for persistent or recurrent staphylococcal blepharitis or for those patients who prefer a solution.
• Seborrheic blepharitis may respond to antifungal agents, such as a short course of itraconazole (5)[C].
FOLLOW-UP
PROGNOSIS
• Symptoms can frequently be improved but are rarely eliminated.
• Long-term eyelid hygiene required for control.
COMPLICATIONS
• Stye and chalazion
• Scarring of eyelid margin
• Corneal infection
PATIENT MONITORING
• Patients should schedule a return visit if their condition worsens despite treatment.
• Return visit intervals for patients with severe disease vary.
• If corticosteroid prescribed, re-evaluate within a few weeks to measure intraocular pressure and determine response to therapy.
REFERENCES
1. American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice patterns Committee. Preferred Practice Pattern: Blepharitis. San Francisco: AAO. 2003.
2. Tsai T, O'Brien JM. Masquerade syndromes: Malignancies mimicking inflammation in the eye. Int Ophthalmol Clin 2002;41:115-131.
3. McCulley JP, Shine WE. Changing concepts in the diagnosis and management of blepharitis. Cornea 2000;19:650-658.
4. Abelson MB, Cohane K, Fink K. Blepharitis: Hiding in plain sight. Rev Ophthalmol May 15. 2004.
5. Ninoyima J, et al. A case of seborrheic blepharitis: Treatment with itraconazole. Nippon Ishinkin Gakkai Zasshi 2002;43:189-191.
ADDITIONAL READING
• Lemp MA. Contact lenses and associated anterior segment disorders: Dry eye, blepharitis, and allergy. Ophthalmol Clin North Am 2003;16:463-469.
• McCulley JP, Shine WE. Eyelid disorders: The meibomian gland, blepharitis, and contact lenses. Eye  Contact Lens 2003;29(1S):S93-95.
• Rao NA, Hidayat AA, McLean IW, Zimmerman IE. Sebaceous carcinomas of the ocular adnexa: A clinicopathologic study of 104 cases, with five year follow-up data. Hum Pathol 1982;13:113-122.
• Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani O. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol 1993;116:88-92.
MISCELLANEOUS
See also: Conjunctivitis; Dry eye syndrome (keratoconjunctivitis sicca)