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BLEFARITISBlepharitis HYPERLINK "" AuthorRoni M Shtein, MDSection EditorJonathan Trobe, MDDeputy EditorLee Park, MDDisclosures: Roni M Shtein, MD Nothing to disclose. Jonathan Trobe, MD Nothing to disclose. Lee Park, MD Employee of UpToDate, Inc. Employment (Spouse): Novartis. Equity Ownership/Stock Options (Spouse): Novartis. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. HYPERLINK "" \t "_blank" Conflict of interest policyAll topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Sep 2014. | This topic last updated: Apr 08, 2014. INTRODUCTION?—?Blepharitis is a chronic eye condition characterized by inflammation of the eyelids. Blepharitis is commonly evaluated by both primary care clinicians and ophthalmologists. One survey in the United States indicates that symptoms associated with blepharitis are quite common [1]. The most frequent patient complaint is of ongoing eye irritation, often accompanied by eye redness. The chronicity of blepharitis is punctuated by intermittent exacerbations.CLASSIFICATION?—?Classification of blepharitis is sometimes based on the composition of tears and meibomian gland secretions. Although such classification is important for research into the etiology and treatment of blepharitis, this classification is not particularly helpful in providing clinical care. For the purpose of this review, we will discuss blepharitis according to its predominant anatomic location, as anterior or posterior.Anterior blepharitis?—?Anterior blepharitis, less common than posterior, is characterized by inflammation at the base of the eyelashes (picture 1). Patients with anterior blepharitis, compared to those with posterior blepharitis, are more likely to be female and younger [2]. Two variants of anterior blepharitis are identified: staphylococcal and seborrheic.●In staphylococcal anterior blepharitis, colonization of the eyelids by staphylococci leads to formation of fibrinous scales and crust around the eyelashes.●The seborrheic variant is characterized by dandruff-like skin changes around the base of the eyelids, resulting in greasy scales around the eyelashes.Posterior blepharitis?—?Posterior blepharitis, the more common condition, is characterized by inflammation of the inner portion of the eyelid, at the level of the meibomian glands (picture 2). It is often described as meibomian gland dysfunction [3]. Meibomian glands are modified sebaceous glands located within the tarsal plates of the eyelids. These glands are responsible for secretion of the oily layer of the tear film. This oily layer prevents tear evaporation, reduces the surface tension of the tear layer, and facilitates the spread of tears over the eye [4]. It is critical for normal lubrication of the eye.Posterior blepharitis can be associated with rosacea or seborrheic dermatitis. Symptoms of these conditions are discussed separately. (See "Overview of dermatitis", section on 'Seborrheic dermatitis' and "Seborrheic dermatitis in adolescents and adults" and "Rosacea: Pathogenesis, clinical features, and diagnosis".)PATHOPHYSIOLOGYAnterior blepharitis?—?The pathophysiology of blepharitis is not completely understood. A role for lid-colonizing staphylococcal bacteria was first noted in 1946 [5]. Several mechanisms by which staphylococci may alter meibomian gland secretion and cause blepharitis are supported by studies [6-9]:●Direct infection of the lids●Evoke reaction to staphylococcal exotoxin●Provoke allergic response to staphylococcal antigens [10]It is likely that a combination of these is responsible for the clinical manifestations of staphylococcal blepharitis.Posterior blepharitis?—?Posterior blepharitis is characterized by inflammation around the meibomian glands. A single row of meibomian glands is present in each lid with openings just anterior to the mucocutaneous junction of the lid margin [4].As noted above, posterior blepharitis is often found in association with skin conditions such as rosacea and seborrheic dermatitis [2]. Rosacea is associated with plugging and hypertrophy of the sebaceous glands [11]. Since the meibomian glands are modified sebaceous glands, rosacea may lead directly to meibomian dysfunction [4]. Seborrheic dermatitis is also associated with inflammation of the meibomian glands and tear film instability [12].An early finding in patients with blepharitis is hyperkeratinization of the meibomian gland ductal epithelium [13]. Additionally, there is a change in the composition of meibomian gland secretions. Secretions from affected patients contain an increase in the concentration of free fatty acids and in the percentage of lipids with higher melting points [2,14-16]. Levels of unsaturated fatty acids and other polar lipids are also increased in the meibomian secretions of patients with blepharitis [17,18]. The differences in lipid composition are thought to be due to both altered production by the abnormal meibomian glands and to chemical changes in the secretions mediated by lipase that is produced by the colonizing bacterial flora on the ocular surface [4,6,19].The bacteria that comprise the lid and conjunctival flora in blepharitis are the same as normal skin flora, but are present in greater numbers [8]. The lid flora is composed principally of coagulase negative staphylococci, corynebacterium species, and propionibacterium acnes [2,7,14]. Bacterial lipase is increased in patients with chronic blepharitis [9].The altered meibomian gland secretions result in an impaired lipid layer of the tear film and instability of the tear film [20]. The abnormal secretions also have a direct toxic effect on the ocular surface [10,16]. Additionally, the altered lipid composition provides an environment that promotes bacterial growth, leading to a cycle of ongoing exacerbation of the meibomian gland abnormalities. Long term gland inflammation leads to fibrosis, dysfunction of the glands, and damage to the eyelid and ocular surface.CLINICAL PRESENTATION?—?Patients with blepharitis often present with symptoms of chronic eye irritation. Common complaints include:●Red eyes●Gritty sensation●Burning sensation●Excessive tearing●Itchy eyelids●Red, swollen eyelids●Crusting or matting of eyelashes in the morning●Flaking or scaling of the eyelid skin●Light sensitivity●Blurred visionCLINICAL EXAMINATION AND DIAGNOSIS?—?The diagnosis of blepharitis is clinical, based on the patient's history and physical examination findings. There are no confirmatory diagnostic tests or laboratory investigations.The history should include questions about symptom duration, smoking, allergens, contact lenses, and use of retinoids, which may provoke or exacerbate symptoms. A history of acne, rosacea, or eczema should be evaluated [21].External examination?—?The patient's facial and scalp skin should be examined for findings typical of seborrheic dermatitis (itching and flaking scalp or facial skin) or acne rosacea (facial flushing, broken or swollen blood vessels on cheeks and nose, and a red or swollen nose).The eyelid edges will often appear pink or irritated. Crusting of the lashes or lid margins may also be visible. The lids should be examined carefully, using a focused light source (penlight or otoscope lamp) if a slit lamp is not available. Patients with anterior blepharitis will typically have adherent material around their eyelashes. In the seborrheic variant these are often greasy appearing flakes; whereas in staphylococcal blepharitis, a hard crust develops around the eyelash as a "collarette" [22].Malposition of the eyelids should be evaluated. Chronic inflammation can lead to structural changes resulting in entropion (inward turning of eyelid) (picture 3) or ectropion (outward turning of eyelid) (picture 4). Eyelashes should be carefully evaluated as chronic inflammation can lead to trichiasis (misdirected eyelashes), madarosis (loss of lashes), poliosis (loss of pigmentation of lashes), or distichiasis (abnormal growth of eyelashes from meibomian gland orifices).Slit lamp examination?—?Slit lamp examination is routinely performed when patients are referred to ophthalmology for evaluation, but is not necessary for initial treatment of blepharitis by primary care clinicians.Eyelids?—?The slit lamp examination can help distinguish anterior and posterior blepharitis. Changes in anterior blepharitis, suggestive of seborrheic or staphylococcal variants, are described above. (See 'External examination' above.) In posterior blepharitis it is common to see enlargement of the meibomian gland openings and plugging with thickened, waxy secretions appearing as white or yellow mounds at the gland opening (picture 5).With any form of blepharitis, chronic inflammation can lead to neovascularization and dilation of existing blood vessels of the lid margin, thickening of the lid skin, irregularity of the lid contour, and ulcerations along the eyelid margin.Conjunctiva?—?Patients with blepharitis will often develop diffuse conjunctival injection. This injection is sometimes more prominent on the palpebral conjunctiva [4]. Blepharitis can also be associated with a papillary conjunctival reaction.Tear film?—?Irregularities of tear film are identifiable by the presence of debris and/or a foamy appearance to the tear film. Abnormalities of tear film stability are assessed by increased tear break up time and increased tear evaporation rate.Tear break up time is evaluated by examining the tear film with a slit lamp using blue light, after instilling fluorescein stain in the eye. A healthy tear film appears as a green sheen that remains stable for at least ten seconds. An abnormal tear film becomes irregular or breaks up in less than ten seconds.Cornea?—?Corneal findings are most commonly found where the inflamed lid margins cross the cornea at the two, four, eight, and ten o'clock positions.Punctate epithelial erosions commonly appear in the inferior third of the cornea [10]. Similar erosions may be associated with dry eyes, but in that condition are more commonly distributed throughout the inter-palpebral space.Patients with blepharitis can develop marginal corneal infiltrates as a hypersensitivity reaction to staphylococcal antigens [23]. These appear as a superficial stromal infiltrate, usually with epithelial breakdown, near the limbus. An area of clear cornea between the limbus and the infiltrate is characteristic.Corneal nodules, called phlyctenules, develop near the limbus and then spread onto the cornea, carrying behind them a leash of vessels. They are considered to be another form of hypersensitivity reaction to staphylococcal antigens [24].Rarely, corneal marginal ulcers can develop in the setting of blepharitis. These must be recognized and treated appropriately to avoid progression to corneal perforation.Chronic irritation and recurrent corneal infiltrates can lead to scarring and development of a superficial corneal pannus, sometimes described as pseudo-pterygium (picture 6).ASSOCIATED OCULAR CONDITIONSHordeolum?—?A hordeolum (commonly referred to as a stye) is an acute infection of an oil gland of the eyelid that presents as an abrupt onset of a red tender bump on the eyelid (picture 7). It can be associated with blepharitis because abnormal oily secretions block lid glands that may become secondarily infected. Treatment involves application of warm moist compresses four times a day. (See "Eyelid lesions", section on 'Hordeolum'.)Chalazion?—?A chalazion is a firm non-tender bump on the eyelid that represents a chronic sterile inflammation of an oil gland of the eyelid (picture 8). The chalazion results from a granulomatous inflammatory reaction to the lipid content of the blocked lid gland [4]. Treatment involves application of warm, moist compresses four times a day. If the symptoms do not respond after several weeks, incision and curettage or intralesional glucocorticoid injection can be performed. (See "Eyelid lesions", section on 'Chalazion'.)Dry eye?—?Patients with blepharitis should be asked about symptoms of dry eyes (picture 9). Abnormal or decreased meibomian gland secretions lead to alterations in the tear film that can result in excess tearing or dry eye. A 25 to 40 percent incidence of dry eyes has been found in patients with blepharitis [25]. Patients often need to use supplemental artificial tear eye drops to treat the dryness. (See "Dry eyes".)Contact lens intolerance?—?Blepharitis is a common finding in patients with contact lens intolerance [26]. The altered lipid layer of the tear film in patients with blepharitis results in reduced contact lens comfort for some patients. Treatment of blepharitis as well as supplemental ocular lubrication may improve contact lens tolerance.TREATMENT?—?The most important initial component of blepharitis treatment is patient education and counseling. Blepharitis is a chronic condition without definitive cure, and a satisfactory result therefore requires a long-term commitment to treatment and appropriate expectations. Goals of treatment are to alleviate acute symptoms of an exacerbation and to develop a maintenance regimen to prevent or minimize future exacerbations.Good lid hygiene is the mainstay of treatment for all forms of blepharitis and should be emphasized in both the acute and maintenance phases of treatment. Recommendations about self-care hygiene and other interventions are based on clinical experience, as randomized trials have not been reported on specific components of self-care.A systematic review of 34 studies (randomized trials and case control studies) of treatments for chronic anterior or posterior blepharitis found that lid hygiene measures provided effective symptom relief for both anterior and posterior blepharitis [27]. The review found that topical antibiotics were effective for providing symptom relief and eradicating bacteria at the lid margin for patients with anterior blepharitis, but did not find conclusive evidence of effectiveness for oral antibiotics or topical glucocorticoids. Warm compresses?—?Application of heat to the lids and meibomian glands can liquefy the abnormal solidified meibomian secretions by heating them above their melting point. Heat may also promote increased circulation in the meibomian glands and thereby increase the quantity of secretions.Patients are advised to soak a wash cloth in warm (not scalding) water and place it over the eyes. As the wash cloth cools, it should be re-warmed and replaced for a total of five to ten minutes of soaking time. This is recommended two to four times a day during the acute phase and at a decreased frequency in the maintenance phase of treatment.Lid massage?—?Lid massage may help empty the meibomian glands and improve secretion, especially in patients with posterior blepharitis and meibomian gland inspissation. Lid massage should be performed immediately following application of a warm compress. Either the wash cloth that was used for the compress or a clean fingertip should be used to gently massage the edge of the eyelid towards the eye with a gentle circular motion.Lid washing?—?Patients with significant accumulation of debris on the eyelashes may benefit from gentle washing of the eyelid margins following use of the warm compress. Either warm water or very dilute baby shampoo can be placed on a clean wash cloth, gauze pad, or cotton swab. The patient is then advised to gently clean along the lashes and lid margin to remove the accumulated material on the lashes with care to avoid contacting the ocular surface. Vigorous washing should be avoided, as this may incite more irritation of the sensitive eyelid mercially available eyelid scrub solutions are safe and effective [28] and may be preferred for their convenience and ease of use [29]. If any soap is used, thorough rinsing is recommended.Antibiotics?—?Since bacterial overgrowth and the lipase activity of colonizing bacteria are known to play a role in the pathophysiology of blepharitis, there is a role for antibiotics in treatment. Additionally, evidence suggests that some antibiotics may have a direct effect on improving meibomian gland function [30,31].Topical antibiotics?—?Topical antibiotic ointments may be helpful in reducing the bacterial load of the lashes and conjunctiva. The ointment is placed directly onto the lid margin up to four times a day. Many prefer to use the antibiotic once daily at bedtime only, since the ointment can cause significant blurring of ical azithromycin ophthalmic solution 1 percent has been shown to improve meibomian gland secretions and to decrease eyelid redness, compared to use of warm compresses alone [32]. A four-week course of topical azithromycin leads to significant improvement in both signs and symptoms of blepharitis [32]. Erythromycin or bacitracin ointments are often prescribed as they have broad spectrum antimicrobial activity and tend to be well-tolerated. Although they can sometimes be associated with contact dermatitis, these ointments are usually the first line of topical antibiotic treatment. Oral antibiotics?—?Long term use of oral antibiotics, especially tetracyclines, may be helpful in severe cases of blepharitis. Tetracyclines effectively reduce the load of colonizing lid and conjunctival bacteria [33]. Tetracyclines also decrease keratinization [34] and bacterial lipase production [35,36]. Tetracyclines may be especially useful in patients with ocular manifestations of rosacea [37]. Furthermore, they are associated with reduction of matrix metalloproteinase activity that may play a role in chronic blepharitis [38]. However, trials comparing tetracycline with placebo in patients with blepharitis are not available.Treatment can be initiated with doxycycline 100 mg or tetracycline 1000 mg daily in divided doses and tapered after improvement (often two to four weeks) to doxycycline 50 mg or tetracycline 250 to 500 mg daily. Treatment can be given in intermittent courses, as indicated by symptom exacerbation. Tetracyclines may cause photosensitization, gastrointestinal upset, and pseudotumor cerebri, as well as interfere with warfarin and the effectiveness of oral contraceptives. Tetracyclines are contraindicated in pregnant or nursing women, and in children under 12 years of age. In lieu of tetracycline and its derivatives, erythromycin or related medications should be used in pregnant patients or children under the age of 12.One small study of adult patients with posterior blepharitis found symptomatic improvement after treatment with intermittent oral azithromycin therapy [39]. Further studies are needed to determine whether intermittent antibiotic therapy is an effective option for treatment of ical glucocorticoids?—?There may be a role for topical glucocorticoid use in the short term treatment of acute blepharitis exacerbations [40]. Patients should generally be evaluated by an ophthalmologist prior to initiation of topical glucocorticoids.It should be emphasized that topical glucocorticoids are not to be used chronically to avoid increasing risk for glaucoma or cataract formation. If glucocorticoids are prescribed, patients should be reevaluated in a few weeks to measure intraocular pressure and to determine ical cyclosporine?—?Topical cyclosporine 0.05 percent eye drops were approved for the treatment of dry eyes by the US FDA in 2002. Several studies have investigated off-label use of these drops in the treatment of blepharitis with promising results. Topical cyclosporine use has led to reduction in symptoms [41] and improved clinical findings in patients with posterior blepharitis [41,42]. Due to its high cost, cyclosporine should be a therapeutic option only when traditional treatments are ineffective.Thermal pulsation systems?—?Devices are available to provide heat and gentle pressure on the eyelid to liquefy and release obstructions in the meibomian glands. In one industry-sponsored, open-label, randomized trial, the LipiFlow? system applied for one 12-minute treatment improved meibomian gland secretion and dry eye symptoms at two and four weeks compared to warm compresses used for five minutes once daily [43]. Whether these short-term results would persist beyond four weeks is not known.SPECIAL CASESUnilateral symptoms and possible malignancy?—?Blepharitis is nearly always bilateral. A malignant tumor of the lid skin (ie, sebaceous carcinoma) should be suspected in a patient with persistent unilateral eyelid inflammation (picture 10) [44-47]. Other symptoms of malignancy include failure to respond to treatment, a nodular mass, ulceration, extensive scarring, or conjunctival nodules surrounded by inflammation [21]. (See "Eyelid lesions", section on 'Sebaceous carcinoma'.)Early recognition of malignancy can reduce morbidity and mortality. Unusual forms of blepharitis should alert the physician to consider biopsy for a pathologic diagnosis.Preoperative patients?—?Care must be taken to diagnose and treat blepharitis in patients prior to proceeding with eye surgery, since blepharitis is associated with increased bacterial colonization of the eyelids [48].Pediatric blepharitis?—?Children can have dramatic episodes of anterior and/or posterior blepharitis, often characterized by more conjunctival and corneal findings than in adults [49,50]. Accurate diagnosis and appropriate treatment in these children is important in order to minimize long-term sequelae of blepharitis.Allergic blepharitis?—?Allergic blepharitis is an acute inflammatory reaction of the skin of the eyelids, usually occurring as a reaction to a contact irritant [51]. The skin of the eyelids will be typically very red, swollen, and itchy. Treatment is aimed at identifying and eliminating use of the offending agent.Demodex folliculorum?—?Demodex is a parasite that commonly inhabits the eyelash follicle in patients with and without blepharitis [52,53]. Although this parasite can cause some changes in the eyelash follicles, there is no evidence that it is directly associated with blepharitis [53]. Ocular demodex folliculorum can be treated with oral ivermectin [54].INFORMATION FOR PATIENTS?—?UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.) ●Basics topics (see "Patient information: Blepharitis (The Basics)" and "Patient information: Stye (hordeolum) (The Basics)" and "Patient information: Chalazion (The Basics)")SUMMARY AND RECOMMENDATIONS●Blepharitis is a chronic eye condition characterized by inflammation of the eyelids, with intermittent acute exacerbations. (See 'Introduction' above.)●Anterior blepharitis primarily affects the eyelashes and is related to staphylococcal colonization or seborrhea. Posterior blepharitis is more common and results from meibomian gland dysfunction, which affects tear composition. Posterior blepharitis may be associated with rosacea or seborrheic dermatitis. (See 'Classification' above.)●Diagnosis of blepharitis is based on clinical findings. A slit lamp examination may be helpful in evaluating characteristic features of the lids, conjunctiva, tear film, and cornea. Patients should be evaluated for concurrent dry eyes. (See 'Clinical examination and diagnosis' above.)●Treatment involves patient education about disease chronicity and need for long-term commitment to a therapy program involving lid hygiene. We recommend regular application of warm compresses, gentle lid massage, and lid washing (Grade 1C). (See 'Treatment' above.)●We suggest topical or systemic antibiotics for more severe cases that do not respond to initial lid hygiene (Grade 2C). Topical (erythromycin or bacitracin ointment) or oral (tetracycline) antibiotics are appropriate. Topical glucocorticoids should be reserved for short-term treatment of acute exacerbations. (See 'Treatment' above.)●Patients with unilateral or other unusual symptoms should be evaluated for the possibility of a sebaceous cell malignancy. Blepharitis should be treated prior to ophthalmologic surgery to decrease risk of bacterial contamination. (See 'Special cases' above.) ................
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