Blepharitis: causes, symptoms and treatment

Blepharitis: causes, symptoms and treatment

Blepharitis is an eye condition affecting the eyelids and can cause clumping and stickiness around the eyelashes. This condition may be diagnosed by an optometrist after a person with blepharitis has these signs pointed out to them by a family member, friend or colleague.

What is blepharitis?

Blepharitis is a common eye condition that is not specific to any one group of people.1 As such, it can affect:1

Blepharitis is a condition of the eyelids around the base of the eyelashes.

  • Children and adults
  • People of all ethnicities
  • People of any gender.

A high proportion of patients seeking help with ocular conditions from health care professionals specializing in eye care are diagnosed with blepharitis. In a 2009 survey, carried out in the US, 37% of patients seen by an ophthalmologist, and almost half (47%) of patients seen by an optometrist had signs of blepharitis.1,2

The total number of cases at any one time in the US is not known, but estimates may be drawn from data from 1982, when there were nearly 600,000 patient consultations about blepharitis.1

Blepharitis is classified as either acute or chronic, with chronic adult blepharitis the most common form of the eye condition.1 Blepharitis is further defined by the exact location of the problem, whether at the front or the back of the eyelid.1

For most purposes, blepharitis is taken to mean the chronic form of eyelid inflammation, which will be the focus of this information page.

The following YouTube video, from the American Academy of Ophthalmology, gives a very short and straightforward visual description of blepharitis.

Here are some key points about blepharitis. More detail and supporting information is in the body of this article.

  • Blepharitis is an inflammatory condition affecting the area around the base of the eyelashes.
  • The acute form of blepharitis is sometimes described as an eyelid infection (bacterial or viral), whereas chronic forms of the inflammatory condition are diagnosed as blepharitis.
  • If the condition affects the top, outer side of the front of the eyelids, it is called anterior blepharitis: a condition with a disease process similar to that of seborrheic dermatitis of the face and scalp.
  • If the condition affects the underside of the front of the eyelids (the moist side in contact with the eye near the eyelashes), it is called posterior blepharitis. This shows a similar disease process to the anterior version, but also specifically affects the little glands that secrete an oily substance onto the eye.
  • While the disease process is well described, the underlying causes of chronic blepharitis are not well understood.
  • Bacteria can be associated with the condition, with Staphylococcus infection more common in women than men.
  • Blepharitis is not caused by poor hygiene.
  • The most obvious signs of blepharitis are redness and stickiness of the eyelid, with clumping of scaly skin around the base of the eyelashes.
  • Treatment aims at relieving symptoms, but is generally not curative, even when prescription drugs or ointments are used. Treatment is typically effective at managing symptoms.
  • Blepharitis treatment is usually lifelong and involves a ten minute cleansing process performed twice daily. The patient applies warm compresses to loosen the crusty skin and then uses a gentle scrub to clear away this dead skin.
  • Blepharitis that affects the glands near the base of the eyelids may also be relieved by massaging the glands to express the (often thicker) contents and clear blockages.

What causes blepharitis?

The cause of blepharitis differs by type, whether acute or chronic, and for the latter cases, by whether it affects the outside or the underside of the eyelids. The underlying reason for the inflammatory condition is not understood, with the "cause" relating instead to observations of the disease processes.3-5

Acute blepharitis can be ulcerative or non-ulcerative:5

  • Ulcerative acute blepharitis is usually caused by an infection - usually bacterial and usually staphylococcal. A viral cause is also possible, such as infection with Herpes simplex and Varicella zoster.
  • Non-ulcerative acute blepharitis is usually an allergic reaction. Examples of this include atopic blepharo-dermatitis, seasonal allergic blepharo-conjunctivitis, and dermato-blepharo-conjunctivitis.

The diagnosis of blepharitis is usually concerned with the chronic forms - the focus of this article. Although academic descriptions classify up to six specific forms of chronic blepharitis,4 for practical purposes it is enough to look at two broad types according to the part of the eyelids affected:1,3-6

  • In anterior blepharitis affecting the outer part of the front of the eyelids, a bacterial (usually staphylococcal) or seborrheic disease process is involved. Seborrhea is poorly understood; it manifests as dandruff when it affects the scalp.7 Patients with anterior blepharitis often also have seborrheic dermatitis of the face and scalp, or another skin condition called acne rosacea.
  • In posterior blepharitis affecting the underside of the front of the eyelids, there is a problem with the glands near the base of the eyelashes (the condition is also known as Meibomian gland dysfunction, MGD). The glands over-secrete their oily substance or become blocked. The reason for this is not well understood, although hormonal causes are suspected and the condition is often associated with acne rosacea. Posterior blepharitis can also be associated with seborrheic dermatitis.

Signs and symptoms of blepharitis

The main features of blepharitis are the following problems with the eyelids:1

  • Itchiness
  • Redness
  • Flaking
  • Crusting.

The crusting may be more prominent on waking in the morning - all of the symptoms generally tend to be worse at this time.1,3,4,6

Complaints also include:1,3,4

  • Sensations of burning, itching, irritation or that there is a foreign body or a grittiness in the eyes
  • Excessive eye watering, tears (epiphora)
  • Conversely, dry eyes (especially with posterior blepharitis)
  • Stickiness of the eyes
  • Oversensitivity to light (photophobia)
  • Intolerance to wearing contact lenses.

Blepharitis is not a sight-threatening problem, but it can result in decreased vision, which can come and go.1,4

The condition usually affects both eyes3,4 - it is bilateral - and if it is present in only one eye, this can lead a physician to suspect an alternative diagnosis.4

The symptoms of chronic blepharitis tend to come and go, with periods of remission (a pause in symptoms) followed by exacerbations (a flare up).3

The next section will discuss signs of blepharitis - that is, the problems visible to a doctor that help them to diagnose the condition.

Diagnosis and tests for blepharitis

Broadly, there are three types of blepharitis: acute blepharitis (which may be diagnosed as lid infection instead); and two chronic forms (which are also known as lid inflammation).3

Chronic blepharitis is usually either anterior blepharitis or posterior blepharitis (also known as Meibomian gland dysfunction, or MGD):3,6

  • Anterior blepharitis affects the outer side of the front of the eyelids
  • Posterior blepharitis affects the underside of the front of the eyelids (the moist side in contact with the eye).

In a case that shows both anterior and posterior blepharitis, the diagnosis is termed marginal blepharitis.3

Doctors will first determine a diagnosis of blepharitis by asking about symptoms (taking a history). After confirmation of symptoms listed above, the doctor will then examine the patient's eyelids and eyes.

Slit-lamp examination to find signs of blepharitis

When carrying out an eye examination, the doctor will look for signs that help them determine the specific type of blepharitis, and the appearance of various features that can help to further sub-diagnose the problem.3

A suspected case of blepharitis is best examined under a slit-lamp.

Initial consultations may involve examinations without any special equipment until a more specialized examination is possible using a slit lamp.

A slit lamp is a specially developed, low-power microscope with an intense thin-beam light source. This lamp allows the doctor to look at the outside of the eyes and the eyelids while the patient's head is held steady by resting the chin and forehead against supports.8

Anyone who has recently had a vision test at their optometrist's office will likely be familiar with this piece of equipment.

Use of a slit lamp usually reveals the following signs of anterior blepharitis:3

  • Redness (erythema) and swelling (edema) of the eyelid margin, and telangiectasia (appearance of small blood vessels because they are widened) on the outside of the eyelid
  • Brittle scales in the eyelashes, forming "collarettes" around the lashes, from the base up as they grow
  • Eyelashes pointing toward the eye (trichiasis) in severe and chronic cases
  • Depigmentation (loss of color) of the eyelashes (poliosis)
  • Loss of eyelashes (madarosis)
  • Ulceration and scarring of the eyelid, and scarring of the cornea.

Posterior blepharitis tends to show the following signs:3

  • Meibomian glands may be capped with oil, dilated, or obstructed
  • The glands' secretions may be thicker
  • Telangiectasia(s) and lid scarring may also be present in the area around the glands.

Examination of the moisture over the eyes can reveal a sign common to all diagnoses of chronic blepharitis - instability in the tear film. This instability in the moisture of the eyes may be a result of rapid evaporation caused by abnormal lipid composition in the secretions from the Meibomian glands.5

Treatment and prevention of blepharitis

Self-care and home treatment of blepharitis

Eyelid hygiene is the mainstay of treatment for both types of blepharitis and is something that should be maintained even when symptoms are in remission.3 Self-care is the most important element of treatment, augmented by help from a doctor or eye care specialist.

Blepharitis cannot be cured, but treatment is successful at managing symptoms.3,4

Symptoms of blepharitis will recur if self-care is not maintained, even after symptoms clear up; believing that the problem has been cured is a false hope.

In addition to home treatment, people with the eyelid inflammation should avoid using cosmetics such as eyeliner, mascara and other make-up around the eyes.4,11

Management of both anterior and posterior forms of blepharitis involves a two-part process of lid hygiene, with a third element added for posterior blepharitis management:3,4,6,9,10

  1. Warm compresses - to loosen crusts
  2. Lid cleansing - to remove crusts
  3. Massage - to express the small oil glands of the eyelids.

A warm compress helps to soften and loosen oily plugs and crusts, by diluting sebum and dilating the ducts of the glands secreting this oil.4,5

Using a warm compress simply means placing a warm cloth over closed eyelids, reheating the compress with warm water when it cools and reapplying for up to 10 minutes.4,5

To ensure safety when using warm compresses and blepharitis treatments, be sure to follow physician advice and to heed the warnings of doctors who have shared patients' experiences in a medical journal:11

  • Dip the cloth in warm water - some patients have suffered facial burns by using a microwave to heat up the wet cloth.
  • Use a soft cloth only - one patient resorted to using a toothbrush and scrubbing vigorously, causing damage to his skin and eye.

After a warm compress has been applied for up to ten minutes, the patient should then cleanse their eyelids. This is done by gently rubbing the margin of the eyelid (at the base of the eyelashes, and where the glands are located) with a cotton swab soaked in a dilute solution of baby shampoo (2-3 drops in about half a cup of warm water).4,5

This lid hygiene needs to be maintained as a self-care regime twice a day every day. Although this is a considerable lifelong commitment, without this hygiene regimen the troublesome symptoms of blepharitis will recur.3,4,6

This hygiene is necessary for both types of blepharitis, and the third element - massage - is necessary for posterior blepharitis (Meibomian gland dysfunction).

Massage helps to express the oily contents of the glands after first loosening the sebum with the warm compress. To do this effectively, use a finger or a cotton-tipped applicator/swab to massage the margin of the eyelid (where the eyelashes and glands are) using small circular motions.3,4,6,9,10

Some patients prefer using warming eye masks to achieve the same effects as the warm cloth compresses. These masks may be more convenient, especially given the need for a twice-daily lifelong regime. Eye scrubs are also available and offer an alternative to the use of dilute baby shampoo.4

Replacement tear drops or "artificial tears" available without a prescription will help to counter the dryness of the eyes caused by blepharitis during the day. Similarly, bland ointments available from the pharmacy may help to retain moistness in the eyes overnight.5

Antibiotics and other prescribed medicines for blepharitis

The American Academy of Ophthalmology (AAO) published their Preferred Practice Pattern guidelines in October 2013, including advice on the assessment, diagnosis and management of blepharitis.13

In brief, the AAO guidelines recommend that physicians:13

  • Attempt to treat moderate to severe blepharitis with eyelid hygiene and topical antibiotics prior to intraocular surgery
  • Avoid the use of costly new technologies (including devices using thermal pulsation) as these are not currently supported by sufficient evidence
  • May prescribe topical antibiotic ointments with or without corticosteroids or oral antibiotics (azithromycin should be used with caution in patients with cardiovascular problems as it may adversely affect heart rhythm)
  • Consider the possibility of carcinoma as a differential diagnosis in patients with chronic blepharitis that does not respond to therapy, particularly if the patient is experiencing a loss of eyelashes).

There is a need for further clinical trials to establish the safety and benefits of drug treatments for blepharitis in addition to current self-care recommendations.12

Recent trials have, however, shown that antibiotics and topical corticosteroids can produce significant improvements.12 Doctors will typically recommend these only when hygiene alone has not worked, although antibiotic ointments are always indicated in acute cases of blepharitis that have a bacterial cause; oral antiviral drugs are prescribed for acute viral cases.5

Combination drug ointments are prescribed by doctors to address both the infectious and inflammatory elements of blepharitis.12

Blepharitis and its Symptoms (Video Medical And Professional 2020).

Section Issues On Medicine: Disease