Blepharitis refers to the group of conditions which are characterised by inflammation of the eyelid margin. Blepharitis can be acute or chronic and can occur at all ages but the most commonly encountered variant is chronic adult disease. This will be described here. Follow links provided throughout this article for information about more acute causes (eg pre-septal cellulitis, herpes simplex virus (HSV) or herpes zoster virus (HZV) infections etc.).
It can be anatomically divided into anterior disease (anterior blepharitis) – which primarily affects the lashes, and posterior disease (posterior blepharitis) – which involves the meibomian glands (and so is sometimes referred to as meibomian gland disease). Anterior blepharitis is broadly divided into staphylococcal blepharitis and seborrhoeic blepharitis. This reflects the underlying pathophysiology to a certain degree, although there is often overlap in a given individual. It is not unusual for the different entities to be difficult to distinguish clinically in primary care.
In most cases the pathogenesis is unclear.
Although some skin commensals are found in higher proportions in these patients (notably, Staphylococcus epidermidis, S. aureus, Propionibacterium acnes and Corynebacterium spp.), infection is not thought to be a major contributing factor, other than in staphylococcal anterior blepharitis.
Seborrhoeic blepharitis is closely associated with seborrhoeic dermatitis and commonly occurs with posterior blepharitis.
Meibomian gland dysfunction may contribute to posterior blepharitis. Their oily secretions are deficient or of poor quality. This results in increased tear evaporation and dry eyes.
Demodex mite infestation can cause blepharitis. They are the most common microscopic ectoparasite found in the human skin and two species have been confirmed as a cause of blepharitis. D. folliculorum can cause anterior blepharitis whilst D. brevis can cause posterior blepharitis. The mites can cause blepharitis through several mechanisms. These include direct damage or a hypersensitivity reaction. Mites may carry bacteria on, or within, their bodies. These bacteria have the potential to cause blepharitis.
There are some conditions that are known specifically to cause blepharitis, including rosacea, herpes simplex or varicella zoster dermatitis, molluscum contagiosum, allergic or contact dermatitis and staphylococcal dermatitis. It may rarely complicate atopic eczema.
Anterior blepharitis can predispose an individual to posterior disease and vice versa.
Ultimately, most individuals presenting with blepharitis are thought to have a combination of causal factors. However, one factor may predominate to give a picture of a particular type of blepharitis.
Incidence is 1.8 per 1,000 per year.
The true prevalence is unknown and studies trying to estimate this have been unsatisfactory.
It accounts for 4.5% of all ophthalmological problems.
All forms are equally common in both sexes, other than staphylococcal blepharitis, which is more common in women.
It is a condition which most commonly starts in the fourth and fifth decades of life.
Sore eyes that are burning (worse in the morning in meibomian disease) and gritty with crusting on waking – usually bilateral and chronic.
The lid margin is injected; look for scales at the base of the lash.
The eye(s) may be red and, occasionally, patients complain of epiphora (excess tears) or dry eye and photophobia.
Blurred vision may occur secondary to epiphora.
There is frequently contact lens intolerance.
There may be long periods of exacerbations and remissions.
Patients with posterior disease tend to be older and have a longer history of symptoms.
Be suspicious of unilateral disease, as lid tumours may present this way.
There are a number of signs, some characteristic to each type of blepharitis and many overlapping where there is mixed pathology.
Anterior blepharitis Staphylococcal Hyperaemia and telangiectasia around lid margin, crusting around base of lashes (= collarettes).
Seborrhoeic Hyperaemia and greasy appearance of anterior lid margin with lashes stuck together. Soft scaling occurs along length of lash. Less inflammation.
Posterior blepharitis Meibomian seborrhoea Meibomian gland orifices (lining the lid margin) are covered with small oil globules. Pressing the tarsus (firm bit within the lid) results in copious expression of meibomian oil.
Meibomianitis Inflammation of the meibomian glands which may be obstructed.
Basal cell carcinoma (BCC).
Contact lens problems.
Dry eye syndrome.
Squamous cell carcinoma (SCC).
This is confirmed by clinical examination:
Lid skin – this may be slightly inflamed. Look for concurrent dermatological conditions: scaly or flaking (especially in anterior disease), vesicles (associated with herpetic infection), telangiectasia or pustules (such as in patients with rosacea). It is particularly important to look for associated lesions that may raise suspicion of BCC or SCC.
Lashes – loss (madarosis) frequently occurs in anterior disease and occasionally happens in long-standing posterior disease.
Be wary of localised lash loss: sebaceous gland carcinoma may mimic chronic blepharitis with localised inflammation and lash loss – refer if unsure.
Look for crusting (collarettes) or hard scales (staphylococcal disease) and for greasiness (seborrhoeic disease). Trichiasis (in-turning of lashes) and poliosis (whitening of lashes) may occur in long-standing disease.
Lid margin – look for inflammation around the meibomian gland orifices (meibomianitis) or the capping of the meibomian gland orifices (looks like a row of yellow droplets along the lid margin) of meibomian seborrhoea.
Tear film – this is frequently deficient in most forms of the disease and it may also be foamy in meibomian seborrhoea.
Conjunctiva – (evert the upper lid); it may be injected, there may be early chalazion formation and scarring can occur in long-standing disease. Associated conjunctivitis may be present.
Cornea – inferior punctate epithelial erosions, scarring and neovascularisation may all be found in more severe forms of the disease. Thinning and ulceration are rare but sight-threatening and warrant immediate referral.
Peripheral examination for associated disease, such as dermatological problems, completes your assessment.
Complement this with a general examination of the eye as well as checking visual acuities.
There are no specific tests: diagnosis is made on examination. Swabbing may be appropriate in severe or recurrent cases and biopsy is mandatory in cases where malignancy is suspected (such as associated suspicious lesions or eyelash loss, usually – but not exclusively – in the older patient).
Blepharitis may occur on its own or in association with any of the conditions outlined in ‘Differential diagnosis’ (above), particularly dry eyes (keratoconjunctivitis sicca). It may also be associated with:
Bacterial infections, eg impetigo, erysipelas.
Viral infections, eg molluscum contagiosum, varicella-zoster virus, papillomavirus.
Eye disease, eg pterygium.
Immune disease, eg erythema multiforme, pemphigoid, connective tissue disorders.
Dermatoses, eg psoriasis, ichthyosis, erythroderma.
Benign eyelid tumours, eg actinic keratosis, haemangioma, pyogenic granuloma.
Malignant eyelid tumours, eg BCC, SCC, melanoma.
Trauma, eg chemical, thermal, surgical.
Meibomian gland disease is particularly associated with chalazia (obstruction + lipogranulomatous inflammation within the gland) and internal hordeolum (acute abscess formation within the gland). Interestingly, a recent study has shown blepharitis to be associated with less obvious systemic disease, including:
Irritable bowel syndrome
Other associations identified included cardiovascular disease (eg carotid artery disease, hyperlipidemia, hypertension, and ischaemic heart disease), hormonal-related problems (eg hypothyroidism and prostatic hypertrophy) and other inflammatory conditions (eg peptic ulcer, asthma and arthropathy).
Patient information – this condition often runs a protracted course and its containment will largely depend on the patient understanding the nature of the problem and what the management issues are. A dependence on a course of antibiotics with no patient input will result in limited – if any – positive results. Patients should be advised to avoid contact lens wear, particularly during acute inflammatory episodes. However, the patient should also be reassured that this condition is rarely sight-threatening and that it should not prevent them from doing all the usual activities of daily living (including swimming, unless there is an acute infection) other than restricting the use of make-up; eye-liner is a particular offender.
Lid hygiene – this is the mainstay of treatment and may be sufficient to control simple low-grade blepharitis. It should also be used regardless of the need for additional treatment. Lid hygiene should be carried out twice a day in the acute phase and once daily at other times. There are three main aspects to this:
Action Method Rationale
Warm compresses Soak a cloth or cotton wool pad with hot water – apply to each eye for 5 (ideally 10) minutes. Avoid excessive heat. Commercial products specifically prepared for this use are available. Loosens collarettes and crusting which makes subsequent cleansing more comfortable. Also, warms the fatty content of the meibomian glands, so making this easier to express during lid massage.
Lid massage (more useful for posterior disease) Close lids and gently rotate a clean finger along lid, ending in a downward stroke (upper lid) and upward stroke (lower lid). Move along the length of each lid. Loosening meibomian gland content and expressing this through the orifices that line the lid margin.
Lid cleansing Mix baby shampoo with water (the quantity that works best varies from patient to patient: start with a 50:50 mix and increase or decrease concentration according to effectiveness). Dip a cotton bud in and then run it along the margin, cleaning off debris from the lash base. Bicarbonate of soda or commercial lid scrubs may also be used. Aim is gentle mechanical washing, vigorous scrubbing is not necessary. This gets rid of collarettes and debris, so reducing margin inflammation.
Managing inflammation – all forms of blepharitis benefit from a short course of weak topical steroids (or a steroid and antibiotic combination) during an acute exacerbation or in severe cases where there is corneal involvement: typically a drop several times a day, tapered over one to three weeks. Intra-ocular steroid drops should only be prescribed by, or under the advice of, an ophthalmologist, due to the not insignificant risks (including raised intra-ocular pressure, cataract formation and potentiation of infection).
Managing infection – if there is an infection despite adequate lid hygiene, you may consider a course of antibiotics.
Chloramphenicol ointment is the first choice (drops are second choice) or fusidic acid where chloramphenicol is contra-indicated, eg myelosuppression during previous exposure to chloramphenicol, presence of blood dyscrasia, pregnant women. There is no contra-indication in breast-feeding women.
Topical antibiotics are helpful in treating acute infections in anterior blepharitis.
Ointments should not be used in conjunction with contact lens wear.
Topical antibiotics should be used for four to six weeks.
Topical antibiotics should be applied after eyelid hygiene routine.
Ointment should be rubbed into the lid margin.
The frequency depends on the severity of the infection but twice-daily is a good option.
Meibomitis responds better to systemic antibiotics over a minimum of six weeks (12 weeks provide a prolonged effect). Options include:
Tetracycline – 500 mg bd for 4 weeks then 250 mg bd for 8 weeks.
Oxytetracycline – 500 mg bd for 4 weeks then 250 mg bd for 8 weeks.
Lymecycline – 408 mg od for 12 weeks.
Doxycycline – 100 mg od for 4 weeks then 50 mg od for 8 weeks.
Avoid if there is likely to be excessive exposure to the sun (risk of photosensitivity), in pregnant or breast-feeding women and in children under the age of 12. In individuals with renal failure, avoid if possible but, if they are essential, doxycycline is a safer option in this group (the others are excreted renally). Other risks associated with tetracycline use are benign intracranial hypertension, gastrointestinal disturbances and, in women, vulvovaginal candidiasis.
Repeated courses of antibiotics may be necessary.
Azithromycin has been put forward as another potential treatment option but is not currently routinely prescribed in the UK. This can be used systemically or topically and may have a role in the reduction of dry eye associated with blepharitis.
You may find the separate articles Eye Drugs – Prescribing and Administering and Antimicrobial Eye Preparations useful.
Managing dry eye – this is a problem frequently encountered by patients suffering from blepharitis. The regular use of artificial tears (eg qds, but adjust up or down after a trial period of a few days according to symptoms) and lubricants is appropriate. Generally, artificial tears are best used in the day and the thicker lubricants are best administered last thing at night. See separate Dry Eyes article.
Managing underlying conditions – these should be addressed as appropriate. This may not completely clear the blepharitis; however, this may go some way towards easing the symptoms and decreasing the intensity of the treatment.
Associated cellulitis, suspected malignancy and corneal involvement all warrant referral, urgently in the case of cellulitis.
If there is a decrease in visual acuity or the patient complains of moderate/severe pain, there may be more than blepharitis going on and referral is then also necessary.
Uncertain diagnosis may also benefit from referral, as may the presence of concurrent disease, depending on its nature.
Complications involving the lid
Chalazion formation: this is a meibomian cyst which is chronic and sterile, filled with lipogranulomatous material. They may be multiple and recurrent but long-standing large ones can be removed in a simple minor operative procedure in an eye unit. They can occasionally get infected: this needs to be treated first with systemic antibiotics prior to incision and curettage.
Stye (external hordeolum): this is a painful, purulent swelling, most prominent on the outside of the eyelid, which arises due to staphylococcal infection of the follicle of an eyelash.
Lid scarring and trichiasis (inward turning of lashes) if chronic.
Antimicrobial Eye Preparations
Complications involving the rest of the eye
Contact lens intolerance is common.
Dry eye syndrome is also common – particularly in posterior blepharitis.
Conjunctivitis – results from infiltration of the conjunctiva with bacterial debris from the eyelid.
Conjunctival cysts (clear fluid-filled blebs) and concretions (little yellow-white fat aggregates embedded in conjunctiva – most often seen on eversion of the inferior tarsus). These tend to be asymptomatic but very large concretions may give rise to a foreign body sensation and can be removed simply with a 25G needle, under slit-lamp examination, with a drop of local anaesthetic in situ.
Keratitis (corneal inflammation) ± ulceration. Symptoms of a foreign body sensation, pain, a red eye and photophobia would lead you to suspect this and should prompt referral for further assessment.
This is a chronic condition which rarely fully resolves.However, with careful, patient and continued adherence to lid hygiene measures (this needs to be reiterated on subsequent visits, even if the eyes are feeling comfortable), symptomatic control is good. It will not permanently damage eyesight if the complications affecting the eyes are treated appropriately.