Blepharitis
BASIC INFORMATION
DEFINITION
This refers to inflammation of the eyelids. The most common form occurs in
association with acne rosacea or seborrheic dermatitis. The eyelid margins
are usually colonized heavily by staphylococci. Upon close inspection, they
appear greasy, ulcerated, and crusted with scaling debris that clings to the
lashes. Treatment consists of warm compresses, strict eyelid hygiene, and
topical antibiotics such as erythromycin. An external hordeolum (sty) is
caused by staphylococcal infection of the superficial accessory glands of Zeis
or Moll located in the eyelid margins. An internal hordeolum occurs after
suppurative infection of the oil-secreting meibomian glands within the tarsal
plate of the eyelid. Systemic antibiotics, usually tetracyclines, are sometimes
necessary for treatment of meibomian gland inflammation (meibomitis) or
chronic, severe blepharitis. A chalazion is a painless, granulomatous
inflammation of a meibomian gland that produces a pealike nodule within the
eyelid. It can be incised and drained, or injected with glucocorticoids. Basal
cell, squamous cell, or meibomian gland carcinoma should be suspected for
any nonhealing, ulcerative lesion of the eyelids.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Chronically infected lids are usually diffusely erythematous, with collarettes (fibrin exudate) at the base of the lashes
• Lid margins thicken over time, with associated loss of eyelashes (madarosis), misdirected growth of lashes (trichiasis), and overflow or inspissation of the meibomian glands
• Associated conjunctivitis with erythema and edema is common, but it is usually without discharge
• Chalazia may develop
• Superficial punctate erosions of the inferior corneal epithelium are common
• More severe findings, such as corneal pannus, ulcerative keratitis, or lid ectropion, are less common
ETIOLOGY
Multiple: bacterial and nonbacterial causes
• Staphylococcal infection
• Seborrheic dermatitis
• Rosacea
• Dry eye (keratoconjunctivitis sicca): includes a decrease in tear volume and/or increased rate of evaporation
• Meibomian gland dysfunction: normally there is keratinization of the meibomian gland duct; hyperkeratinization can plug up the duct
• Two categories of blepharitis:
1. Anterior blepharitis, most often associated with staphylococcal infection or seborrheic dermatitis
2. Posterior blepharitis, associated with meibomian gland dysfunction
Note: Most often bacteria isolated from blepharitis patients are normal skin microflora, but in greater amounts (mostly S. epidermidis and P. acnes). (S. aureus and coagulase-negative staphylococci can be cultured from the eyelid margins of 12% to 40% and 91% to 96% of healthy persons, respectively.)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Keratoconjunctivitis sicca
• Eyelid malignancies
• Herpes simplex blepharitis
• Molluscum contagiosum
• Phthiriasis palpebrarum
• Phthirus pubis (pubic lice)
• Demodex folliculorum (transparent mites)
• Allergic blepharitis
WORKUP
• Scrapings of the eyelids to show polymorphonuclear leukocytes and gram-positive cocci
LABORATORY TESTS
Eyelid cultures and antibiotic sensitivity testing (usually not done unless patient fails to respond to initial treatment regimen)
TREATMENT
NONPHARMACOLOGIC THERAPY
• Lid scrubs are the oldest and most effective treatment.
• Alkaline soaps may be beneficial; alcohol and some detergents may be effective in removing surface lipids and microflora.
• Hot compresses applied to closed lids for 5 to 10 minutes: heat loosens debris from lid margins and increases meibomian gland fluidity.
• Firm massage of the lid margins to enhance the flow of secretions from glands, followed by cleansing of the lids with cotton-tipped applicators dipped in a 50:50 mixture of baby shampoo and water.
• Lashes and lid margins scrubbed vigorously while the eyelids are closed, followed by thorough rinsing.
• Following local massage and cleansing, the mainstay of treatment is application of topical antibiotic ointment to the eyelid margins.
• Antibiotics must be in ointment form for lids and drops or ointment for the ocular surface.
1.1. Most effective topical antibiotics available are bacitracin and erythromycin ophthalmic ointments; also effective are many aminoglycosides and fluoroquinolones.
2. Ointment is applied one to four times daily, depending on the severity of inflammation, for 1 to 2 week.
3. Treatment is continued once daily, at bedtime, for another 4 to 8 week.
4. Treatment is continued for 1 mo after all signs of inflammation have disappeared.
For patients with rosacea:
1. Tetracycline 250 mg orally qid or doxycycline 100 mg orally bid along with local treatment
2. Dosing reduced to once daily for several mo, depending on the clinical situation
Recalcitrant cases with antibiotic resistance:
1. Vancomycin eyedrops 1-2%
2. Ciprofloxacin or ofloxacin eyedrops
CHRONIC Rx
By definition, this is a chronic condition for which there is often no cure. This is complicated by the fact that long-term use of antibiotics results in development of resistance and crossresistance.
Some newer agents being evaluated are flavonoid-type compounds (resveratrol, silymarin) that have antioxidant properties (may have a role in reducing the inflammatory response), and azelaic acid and glycolic acid (used to treat acne and have antikeratinizing effects).
Adapalene gel is also useful in treating acne; it has antiinflammatory properties and an antiproliferative effect on keratinocytes.
• Chronically infected lids are usually diffusely erythematous, with collarettes (fibrin exudate) at the base of the lashes
• Lid margins thicken over time, with associated loss of eyelashes (madarosis), misdirected growth of lashes (trichiasis), and overflow or inspissation of the meibomian glands
• Associated conjunctivitis with erythema and edema is common, but it is usually without discharge
• Chalazia may develop
• Superficial punctate erosions of the inferior corneal epithelium are common
• More severe findings, such as corneal pannus, ulcerative keratitis, or lid ectropion, are less common
ETIOLOGY
Multiple: bacterial and nonbacterial causes
• Staphylococcal infection
• Seborrheic dermatitis
• Rosacea
• Dry eye (keratoconjunctivitis sicca): includes a decrease in tear volume and/or increased rate of evaporation
• Meibomian gland dysfunction: normally there is keratinization of the meibomian gland duct; hyperkeratinization can plug up the duct
• Two categories of blepharitis:
1. Anterior blepharitis, most often associated with staphylococcal infection or seborrheic dermatitis
2. Posterior blepharitis, associated with meibomian gland dysfunction
Note: Most often bacteria isolated from blepharitis patients are normal skin microflora, but in greater amounts (mostly S. epidermidis and P. acnes). (S. aureus and coagulase-negative staphylococci can be cultured from the eyelid margins of 12% to 40% and 91% to 96% of healthy persons, respectively.)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Keratoconjunctivitis sicca
• Eyelid malignancies
• Herpes simplex blepharitis
• Molluscum contagiosum
• Phthiriasis palpebrarum
• Phthirus pubis (pubic lice)
• Demodex folliculorum (transparent mites)
• Allergic blepharitis
WORKUP
• Scrapings of the eyelids to show polymorphonuclear leukocytes and gram-positive cocci
LABORATORY TESTS
Eyelid cultures and antibiotic sensitivity testing (usually not done unless patient fails to respond to initial treatment regimen)
TREATMENT
NONPHARMACOLOGIC THERAPY
• Lid scrubs are the oldest and most effective treatment.
• Alkaline soaps may be beneficial; alcohol and some detergents may be effective in removing surface lipids and microflora.
• Hot compresses applied to closed lids for 5 to 10 minutes: heat loosens debris from lid margins and increases meibomian gland fluidity.
• Firm massage of the lid margins to enhance the flow of secretions from glands, followed by cleansing of the lids with cotton-tipped applicators dipped in a 50:50 mixture of baby shampoo and water.
• Lashes and lid margins scrubbed vigorously while the eyelids are closed, followed by thorough rinsing.
• Following local massage and cleansing, the mainstay of treatment is application of topical antibiotic ointment to the eyelid margins.
• Antibiotics must be in ointment form for lids and drops or ointment for the ocular surface.
1.1. Most effective topical antibiotics available are bacitracin and erythromycin ophthalmic ointments; also effective are many aminoglycosides and fluoroquinolones.
2. Ointment is applied one to four times daily, depending on the severity of inflammation, for 1 to 2 week.
3. Treatment is continued once daily, at bedtime, for another 4 to 8 week.
4. Treatment is continued for 1 mo after all signs of inflammation have disappeared.
For patients with rosacea:
1. Tetracycline 250 mg orally qid or doxycycline 100 mg orally bid along with local treatment
2. Dosing reduced to once daily for several mo, depending on the clinical situation
Recalcitrant cases with antibiotic resistance:
1. Vancomycin eyedrops 1-2%
2. Ciprofloxacin or ofloxacin eyedrops
CHRONIC Rx
By definition, this is a chronic condition for which there is often no cure. This is complicated by the fact that long-term use of antibiotics results in development of resistance and crossresistance.
Some newer agents being evaluated are flavonoid-type compounds (resveratrol, silymarin) that have antioxidant properties (may have a role in reducing the inflammatory response), and azelaic acid and glycolic acid (used to treat acne and have antikeratinizing effects).
Adapalene gel is also useful in treating acne; it has antiinflammatory properties and an antiproliferative effect on keratinocytes.
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