Blepharitis

Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. The typical presentation of blepharitis includes eyelid edema with itching and redness, crusts and scales around the eyelashes, and gritty sensation. Diagnosis is clinical, with a slit-lamp examination providing details of the structural changes affecting the eye. The mainstay of treatment is eyelid hygiene using warm compresses and eyelid scrubs. In moderate-to-severe cases, topical and oral antibiotics are utilized. Topical glucocorticoids also help improve symptoms but require an ophthalmology evaluation due to potential adverse effects.

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Overview

Definition

  • Inflammation of the eyelid margin
  • Chronic recurrent irritation can lead to eyelid scarring and affect the surrounding structures (cornea and conjunctiva).

Anatomy

  • Eyelids protect the eyes from injury and light. 
  • Eyelid layers (from superficial to deep):
    • Skin
    • Loose subcutaneous tissue
    • Orbicularis oculi muscle:
      • Closes the eyelids
      • Assists in tear drainage
    • Tarsal plate: 
      • Connective tissue that gives structural rigidity to the eyelid
      • Contains the meibomian glands
      • The levator palpebrae superioris muscle is inserted into the superior tarsal plate.
    • Palpebral conjunctiva: covers the inner surface of eyelids
  • Eyelid glands:
    • Meibomian glands
      • Modified sebaceous glands with openings behind the eyelashes
      • Meibum (lipid-rich secretion): prevents evaporation of tears and evens out tear film over the surface of the eye
    • Gland of Moll
      • Modified sweat glands 
      • Orifice between adjacent lashes
    • Gland of Zeis
      • Sebaceous gland 
      • Orifice into the eyelash follicle
  • Eyelashes:
    • Protect the eyes from particles or debris, which can cause infection or injury
    • Arranged in double or triple rows at the mucocutaneous junction

Types

  • Categorized based on anatomical location but often overlap 
  • Posterior blepharitis: 
    • More common
    • Primarily caused by meibomian gland dysfunction/blockage
    • Involves the meibomian glands, tarsal plate, and blepharo-conjunctival junction
  • Anterior blepharitis: 
    • Inflammation around the eyelid skin, base of the eyelashes, and lash follicles
    • Variants:
      • Staphylococcal blepharitis: crust around eyelashes caused by Staphylococcus aureus and coagulase-negative Staphylococci
      • Seborrheic blepharitis: greasy scales and crust around the base of eyelids with flaky skin changes
Sagittal cut of the upper eye lid

Sagittal cut of the upper lid featuring its internal structures

Image by Lecturio.

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Pathophysiology and Etiology

Pathophysiology

  • Posterior blepharitis:
    • Functional abnormality of the meibomian glands → altered meibum composition
    • Wax-like secretions can block gland orifices.
    • Stagnant material and altered lipid composition → promotes bacterial growth → inflammation
    • Chronic inflammation damages eyelid structure and further facilitates gland dysfunction.
  • Anterior blepharitis: mechanism not fully understood but pathways include
    • Direct infection from Staphylococcus colonization 
    • Irritation from bacterial toxins and cell-mediated inflammatory response from antigens
    • Implication of parasitic infestation (Demodex mites): Treatment of Demodex improves refractory blepharitis but exact role is still unclear.

Etiology

  • Skin diseases
    • Seborrheic dermatitis
      • Usually causes anterior blepharitis
      • Honey-colored crusts along the rims of eyelids around the eyelashes
    • Rosacea 
      • Usually causes posterior blepharitis
      • Inflammatory disorder resulting in flushing and facial redness
    • Atopic dermatitis
      • Characterized by scales along the lash line, edema, and hyperemia 
    • Psoriasis
      • Manifests with swollen eyelids and crusting of the eyelashes
      • Associated with well-defined plaques with scales in elbows and knees
  • Infections
    • Bacterial infection
      • Staphylococcal dermatitis (most common)
      • Commonly associated with anterior blepharitis
    • Viral infection
      • Molluscum contagiosum
      • Varicella zoster dermatitis
      •  Herpes simplex dermatitis
    • Parasitic infestation
      • Demodex folliculorum (in eyelid follicles): causes anterior blepharitis 
      • Demodex brevis (in meibomian glands): causes posterior blepharitis
      • Not all with infestation develop blepharitis
  • Others
    • Irritants and allergens
      • Swollen, itchy erythematous eyelids
      • Improves with removal of offending agent
    • Medications: retinoids
      • Causes posterior blepharitis
      • Improves with discontinuation of medication

Clinical Presentation

Symptoms

  • Typically bilateral
  • Chronic, episodic red, swollen, itchy eyelids
  • Gritty or burning sensation
  • Watery eyes
  • Skin crusting and scaling on the eyelid margin and eyelashes
  • Matting of eyelashes in the morning
  • Transient blurred vision
  • Vesicles and ulcerations found in herpes or varicella infections

Signs

  • Slit-lamp examination of posterior blepharitis:
    • Enlarged meibomian gland openings
    • Plugged glands with thick, waxy, white or yellow secretions
  • Slit-lamp examination of anterior blepharitis:
    • Erythema and edema of eyelid margin
    • Telangiectasias on outer eyelid
    • Collarette: ring-like crust around eyelashes (Staphylococcus)
    • Sleeve: cylindrical dandruff (Demodex infestation)
    • Greasy flakes (seborrheic type)
    • Madarosis: loss of lashes
    • Poliosis: whitening of lashes
    • Trichiasis: misdirection of lashes
    • Entropion: inward turning of eyelid
    • Ectropion: outward turning of eyelid
  • Other findings:
    • Conjunctival injection
    • Tear film stability: tear break-up time < 10 seconds considered abnormal
    • Cornea:
      • Erosions: from inflamed lid margins 
      • Infiltrates and phlyctenules (corneal nodules): hypersensitivity reaction to staphylococcal antigens
      • Ulcers
      • Scarring from chronic irritation

Diagnosis and Management

Diagnosis

  • Clinical, based on the signs and symptoms
  • In refractory cases: microscopic examination of the eyelashes to check for Demodex mites helps if with typical presentation (sleeves on eyelashes)

Management

  • Eyelid hygiene
    • Mainstay treatment for blepharitis
    • Warm compresses (10 minutes, 4 times/day) to soften crusts/scales and warm the secretions
    • Lid massage to express secretions
    • Lid wash to clear away debris
    • Artificial tears to relieve dryness
  • Eliminate triggers or offending agent
  • Demodex-associated disease
    • Tea tree oil eyelid and shampoo scrubs: shown to be effective 
    • Oral ivermectin
  • Topical antibiotics 
    • If initial symptomatic measures fail
    • Eradicates bacteria in the lashes and conjunctivae
    • Options: bacitracin, erythromycin, azithromycin
  • Oral antibiotics
    • For chronic-moderate to severe blepharitis
    • For blepharitis not responding to topical medications
    • Options: doxycycline, minocycline, zithromax
  • Topical glucocorticoids
    • Only prescribed after evaluation from an ophthalmologist
    • Can increase intraocular pressure so follow-up is required for reevaluation
  • Topical cyclosporine
    • For blepharitis resistant to standard therapies

Differential Diagnosis

  • Conjunctivitis: inflammation of the conjunctiva, the outer lining of the eye. Etiology can be infectious or non-infectious. Patients present with redness and discharge on 1 or both eyes. Bacterial conjunctivitis often has purulent discharge whereas viral causes have watery discharge.
  • Dacryocystitis: inflammation of the nasolacrimal sac commonly caused by duct obstruction. The condition presents as redness and swelling in the area of the tear duct. Tear stasis facilitates bacterial overgrowth and infection occurs, manifesting as mucopurulent discharge. For management, warm compresses are applied and antibiotics are given if indicated. For persistent obstruction, nasolacrimal duct intubation and other surgical interventions are treatment options.
  • Hordeolum (stye): an abscess affecting the eyelash follicle or eyelid gland. The condition usually presents as a locally painful, erythematous, swollen eyelid margin. Most lesions resolve spontaneously, but gentle warm compresses facilitate drainage. If the abscess does not resolve, incision and drainage by an ophthalmologist are performed.
  • Chalazion: a firm, nontender mass at the eyelid resulting from obstruction of the Zeis or meibomian glands. The condition is usually managed conservatively with warm compresses. Persistence of the lesion requires incision and curettage or glucocorticoid injection by an ophthalmologist.

References

  1. Denniston, A., Murray, P. (2014) Oxford Handbook of Ophthalmology, Third edition.Oxford University Press.
  2. Eberhardt, M., Rammohan, G. (2020). Blepharitis. https://www.ncbi.nlm.nih.gov/books/NBK459305/
  3. Lowery, R., Law, S., Dahl, A.(2019). Adult Blepharitis. Retrieved September 23, 2020, from https://emedicine.medscape.com/article/1211763-overview
  4. Putnam,C. (2016) Diagnosis and management of blepharitis. Clin Optom (Auckl), 8: 71–78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095371/
  5. Schtein, R.,Jacobs, D., Givens, J. (2020). Blepharitis. UpToDate. Retrieved September 23, 2020, from https://www.uptodate.com/contents/blepharitis?search=blepharitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

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