Blepharitis is a complex disorder with a number of causes and overlapping signs and symptoms. In primary care, diagnosing blepharitis is often difficult, particularly distinguishing the different types of blepharitis. Blepharitis is often associated with systemic diseases, such as rosacea, atopy, and seborrheic dermatitis2.
Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease2. Chronic inflammation may lead to the development of ulcerative blepharitis, loss of eyelashes and corneal involvement, including punctate epithelial erosions, marginal infiltrates, and neovascularization3.
Blepharitis is typically a chronic condition that cannot be permanently cured. Long-term management is generally based on daily eyelid hygiene and the use of therapeutic agents, such as topical and oral antibiotics and, in some cases, topical anti-inflammatory agents such as corticosteroid3.
Blepharitis is one of the common ocular disorders, and accounts for about 5% of all ophthalmological problems presenting in primary care in the UK1. Blepharitis is more common in older adults, but can occur at any age1.
The prevalence of clinically diagnosed MGD varies widely, with a suggestion that MGD is significantly more common among Asian populations than Caucasian populations7. The prevalence of MGD appears to be higher with 46.2% in the Bangkok study, 60.8% in the Shihpai Eye study, 61.9% in a Japanese study, and 69.3% in the Beijing Eye Study and contrast sharply with reports from populations with a majority of Caucasians which, in turn, range from 3.5% in the Salisbury Eye Evaluation study to 19.9% in the Melbourne Visual Impairment Project7.
In general, the most common signs of blepharitis include:
Most people experience periodic remissions, relapses and exacerbations of symptomatic blepharitis. Seborrheic dermatitis can also be associated with symptoms of scalp itching, flaking, and oily skin. Rosacea can be associated with a red and swollen nose, facial flushing, broken and distended vessels in the face, pustules, oily skin, food and environmental intolerances, and eye irritation.
Loss of eyelashes and corneal involvement, secondary alterations to conjunctiva (conjunctivitis), including punctate epithelial erosions, marginal infiltrates, and neovascularization, may occur. Sties and chalazia are also common1,5,9,10.
The underlying causes of blepharitis are not fully understood, but probably involve several pathogenic mechanisms. The pathophysiology of blepharitis frequently involves bacterial colonization of the eyelids2,3. Blepharitis can be caused by staphylococcal infection, seborrheic dermatitis, meibomian gland dysfunction, or any combination of these.
Blepharitis is also associated with ocular diseases, such as dry eye syndromes, chalazion, trichiasis (eyelashes are misdirected and grow inwards toward the eye), ectropion (eyelid turning outward) and entropion (inversion of the eyelid margin), infectious or other inflammatory conjunctivitis and keratitis2.
Blepharitis can be classified according to anatomic location. Anterior blepharitis affects the eyelid skin, base of the eyelashes and the eyelash follicles. Posterior blepharitis affects the meibomian glands and gland orifices3.
Anterior blepharitis has traditionally been further subcategorized clinically3:
Characterized by scaling, crusting and erythema of the eyelid margin with collarette formation at the base of the cilia. The most common organisms isolated from patients with chronic anterior Staphylococcal blepharitis are Staphylococcus aureus, Staphylococcus epidermidis, Corynebacteria and Propionibacterium acnes.
Characterized by greasy scaling of the anterior eyelid, frequently with seborrheic dermatitis of the eyebrows and scalp. Seborrheic anterior blepharitis is closely associated with seborrheic dermatitis and the two conditions may coexist. Oily secretions are increased and the affected skin is scaly.
Posterior blepharitis (meibomian blepharitis) is a chronic abnormality commonly characterized by duct obstruction and qualitative/quantitative changes in the glandular secretion.
The meibomian secretions become more wax like 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 and oily discharge 12,13.
Blepharitis, if not recognized and appropriately managed can lead to worsening of signs and symptoms. It can disrupt tear film, cause discomfort and change in visual function and negatively impact patient’s quality of life14.
Detection and appropriate treatment1,3 can reduce signs and symptoms of blepharitis, and in severe cases, prevent permanent structural damage and possible vision loss. The patient must understand that a cure is usually not possible.
These treatment options are often used in combination. Eyelid cleansing is especially useful for anterior blepharitis while warm compresses are especially helpful for posterior blepharitis and MGD 1,3.
Compliance with treatment, especially eyelid hygiene, is essential, and this should be continued even when symptoms are well controlled.
The patient should be advised on importance of good eyelid hygiene as the mainstay of treatment. The eyelids should be cleaned in a stepwise manner and involves: Applying a warm compress or a clean cloth warmed with hot water to the closed eyelids for 5–10 minutes. It loosens crusts and helps in melting of the wax like secretions of meibum leading to the expression of secretions through the orifices that line the lid margin.
For posterior blepharitis, the closed eyelids should be massaged in a circular motion along the length of each lid. This aids expression of meibomian gland secretions.
The eyelids should be cleaned by a by gentle mechanical washing, which clears the debris and therefore reduces inflammation of the eyelid margin. Wetting a cloth or cotton bud with cleanser (for example, baby shampoo diluted 1:10 with warm water) can be used for wiping along the lid margins. The optimal dilution factor of baby shampoo with water is often recommended as providing a good balance between irritating and cleaning actions. Eyelid scrubs or wipes can be used to clear away the scales on the lashes.
If there are symptoms of dry eye syndrome, prescribe artificial tears or an ocular lubricant to relieve symptoms.
Prescribing topical or oral antibiotics can be considered if there are clear signs of staphylococcal infection or Meibomian cyst (chalazion) (meibomian-cyst chalazion) respectively. Antibiotics should usually be reserved for second line use when eyelid hygiene alone has proved ineffective.
If there is evidence of seborrhoeic dermatitis and /or acne rosacea, ensure these conditions are adequately treated1,3.
Topical corticosteroids (e.g., drops) may help to decrease inflammation in blepharitis in an acute exacerbation. However, corticosteroids may have significant adverse effects and should only be initiated by an ophthalmologist in secondary care1,3.
Prescribing artificial tears and ocular lubricants1,3
Patients with mild blepharitis should be advised to return to their health care professionals if their condition worsens. Visit intervals for patients are based on the severity of symptoms and signs, the current therapy, and comorbid factors such as glaucoma in patients who have been treated with corticosteroids1,3.
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