Authored by
R Scott Lowery, MD, Staff Physician, Department of
Ophthalmology, University of Arkansas for Medical
Sciences
Coauthored by Hampton Roy, Sr, MD, Clinical Associate
Professor, Department of Ophthalmology, University of Arkansas for Medical
Sciences
Edited by Fernando H Murillo-Lopez, MD, Instructor,
Department of Ophthalmology, Bolivian National Institute of Ophthalmology;
Donald S Fong, MD, MPH, Assistant Clinical Professor of
Ophthalmology, UCLA School of Medicine; Consulting Physician, Department of
Ophthalmology, Southern California Permamente Medical Group; Christopher
J Rapuano, MD, Co-Chairman of Refractive Surgery Department, Associate
Professor, Cornea Service, Wills Eye Hospital, Jefferson Medical College;
Lance L Brown, OD, MD, Ophthalmologist, Regional Eye Center,
Affiliated With Freeman Hospital and St John's Hospital, Joplin, Missouri; and
Hampton Roy, Sr, MD, Clinical Associate Professor, Department
of Ophthalmology, University of Arkansas for Medical Sciences
eMedicine Journal, August 2 2001, Volume 2, Number
8
 |
INTRODUCTION |
Section 2 of 10    |
Background:
Blepharitis refers to a family of inflammatory disease processes of the
eyelid. Blepharitis can be divided best anatomically into anterior and posterior
blepharitis. Anterior blepharitis refers to inflammation mainly centered around
the eyelashes and follicles, while the posterior variant involves the meibomian
gland orifices. Anterior blepharitis usually is subdivided further into
staphylococcal and seborrheic variants. Frequently, a considerable overlap
exists in these processes in individual patients. Blepharitis often is
associated with systemic diseases, such as rosacea and seborrheic dermatitis, as
well as ocular diseases, such as dry eye syndromes, chalazion, trichiasis,
conjunctivitis, and keratitis.
Pathophysiology: The pathophysiology of blepharitis involves
bacterial colonization of the eyelids. This results in direct microbial invasion
of tissues, immune system–mediated damage, or damage caused by the production of
bacterial toxins, waste products, and enzymes. Colonization of the lid margin is
increased in the presence of seborrheic dermatitis or meibomian gland
dysfunction.
Frequency:
- In the US: Blepharitis is a common eye disorder in the US
and abroad.
Mortality/Morbidity: Mortality has not been associated with
blepharitis. Associated morbidity includes loss of visual function, well-being,
and ability to carry out daily life activities. The disease process can result
in damage to the lids with trichiasis, notching entropion, and ectropion.
Corneal damage can result in inflammation, scarring, loss of surface smoothness,
and loss of optical clarity. If severe inflammation develops, corneal
perforation can occur.
Race: No studies demonstrate racial differences in the
incidence of blepharitis. Rosacea may be more common in fair-skinned
individuals, although this only may be because it is more easily and frequently
diagnosed in these individuals.
Sex: No well-designed studies of differences in the
incidence and clinical features of blepharitis between the sexes exist.
Age: Seborrheic blepharitis is more common in an older age
group. The apparent mean age is 50 years.
History:
Patients with blepharitis present with symptoms of eye irritation.
- Common complaints include the following:
- Crusting and mattering of the lashes and medial canthus
- The condition most typically has a chronic course with intermittent
exacerbations and eruptions of symptomatic disease. Seborrheic dermatitis can
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, and eye
irritation.
Physical:
- External examination of patients with blepharitis often demonstrates
findings of associated conditions. Herpetic skin disease can be associated
with erythema and vesicle formation. Seborrheic dermatitis is typified by oily
skin and flaking from the scalp or brows. Rosacea is associated with pustules,
rhinophyma, telangiectasias, erythema, and pustules.
- Gross examination of the eyelids shows erythema and crusting of the lashes
and lid margins.
- Slit lamp examination shows additional features, including loss of lashes
(madarosis), whitening of the lashes (poliosis), scarring and misdirection of
lashes (trichiasis), crusting of the lashes and meibomian orifices, eyelid
margin ulcers, plugging and “pouting” of the meibomian orifices,
telangiectasias, and lid irregularity (tylosis).
- The conjunctiva shows papillary injection.
- Corneal findings can include punctate epithelial erosions, marginal
infiltrates, marginal ulcers, pannus, and phlyctenule formation. Corneal
involvement occurs most commonly at the positions where the limbus is crossed
by the upper and lower lid margins, at the 2-, 4-, 8-, and 10-o’clock
positions. Corneal infiltrates can progress to infection and even
perforation.
- The anterior variant of blepharitis involves mainly the lashes and
associated oil glands. Various formations of debris adhere to the
lashes.
- Crusting refers to flakes of material that adhere to the lashes and
usually represents seborrheic disease.
- A collarette is a ringlike formation around the lash shaft that occurs
with staphylococcal disease. Staphylococcal blepharitis is typified by the
formation of collarettes on the lashes.
- A sleeve is a tube of material that also surrounds the lash. Sleeving is
associated with infection by the eyelash parasite,
Demodex.
- Ulcers form at the base of the lashes. They are covered by a crust of
fibrin, which is lifted up as the lash shaft grows.
- Seborrheic blepharitis also involves primarily the anterior lid and is
associated with the formation of greasy crusts of material, which are
adherent to the eyelash shaft.
- Corneal disease is most common with the staphylococcal variant of anterior
lid disease.
- Posterior blepharitis mainly is related to dysfunction of the meibomian
glands. Alterations in secretory metabolism and function lead to disease. The
meibomian secretions become more waxlike 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. These
processes lead to gland plugging, inspissated material, inflamed orifices, and
formation of chalazia.
- Corneal changes also can result from posterior blepharitis.
Causes:
- Some specific causes of blepharitis may include the following:
- Herpes simplex dermatitis
- Varicella-zoster dermatitis
- Allergic or contact dermatitis
- Staphylococcal dermatitis
- Chronic blepharitis has been associated with exposure to chemical fumes,
smoke, smog, and other irritants.
- Acute blepharitis most commonly is due to allergic drug or chemical
reaction.
| |
DIFFERENTIALS |
Section 4 of 10 |
Basal Cell Carcinoma, Eyelid
Blepharitis, Adult
Cellulitis,
Preseptal
Chalazion
Conjunctivitis,
Bacterial
Conjunctivitis, Viral
Contact Lens Complications
Dermatitis, Contact
Dry Eye Syndrome
Hordeolum
Keratitis, Bacterial
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Epidemic
Keratoconjunctivitis, Sicca
Keratoconjunctivitis, Superior
Limbic
Ocular
Rosacea
Trichiasis
Other Problems to be Considered:
Seborrheic dermatitis
Rosacea
Herpetic eye disease
Lab Studies:
- In general, no diagnostic tests need be performed for a suspected
blepharitis. Research and other rare protocols may involve eyelid margin
cultures, transillumination studies of the meibomian glands, marginal
biopsies, or even analysis of gland secretions.
- Testing patients with blepharitis for tear insufficiency or nasolacrimal
drainage problems is appropriate because these can be associated with
blepharitis and often complicate management.
Histologic
Findings: Seborrheic dermatitis is characterized histologically by
spongiosis, mild perivascular, lymphohistiocytic, mononuclear cellular
infiltrates in the superficial dermis. Staphylococcal blepharitis is a chronic
nongranulomatous inflammation, usually with neutrophils and, often, acanthosis
or parakeratosis.
| |
TREATMENT |
Section 6 of 10 |
Medical Care:
A systematic and long-term commitment to a program of eyelid margin
hygiene is the basis of treatment for blepharitis. Clinicians must ensure that
patients recognize that the management of blepharitis is a process, which must
be carried out for prolonged periods of time. This understanding helps reduce
“doctor shopping,” a process in which a patient goes from physician to
physician, seeking some panacea for this frustrating condition.
- Many appropriate systems of eyelid hygiene exist, and all include
variations of 3 essential steps.
- First, application of heat to warm the eyelid gland secretions and to
promote evacuation and cleansing of the secretory passages is essential.
Patients commonly are directed to use soaked warm compresses and to apply
them to the lids repeatedly. Warm water in a washcloth, soaked gauze pads,
or microwaved, soaked cloths can be used.
- Second, the eyelid margin is washed mechanically to remove adherent
material, such as collarettes and crusting, and to clean the gland orifices.
This can be completed with a warm washcloth or with gauze pads. Water often
is used, although some clinicians prefer that a few drops of baby shampoo be
mixed in one bottle cap full of warm water to form a cleaning solution.
Attention must be directed to gentle mechanical jostling or scrubbing of the
eyelid margin itself, not the skin of the lids or of the bulbar conjunctival
surface. Vigorous scrubbing is not necessary and may be harmful.
- The third step is application of an antibiotic ointment to the eyelid
margin after it has been soaked and scrubbed. Commonly used agents include
erythromycin or sulfacetamide ointments for long-term use.
Antibiotic-corticosteroid ointment combinations can be used for short
courses, although their use is less appropriate for long-term
management.
- Specific clinical situations may require additional treatment. Refractory
cases of blepharitis often respond to oral antibiotic use. One or two month
courses of tetracycline often are helpful in reducing symptoms in patients
with more severe disease. Tetracycline is believed not only to reduce
bacterial colonization but to alter metabolism and reduce glandular
dysfunction. The use of metronidazole currently is being studied.
- Tear film dysfunctions can prompt use of artificial tear solutions, tear
ointments, and closure of the puncta. Associated conditions such as herpes
simplex, varicella-zoster, or staphylococcal skin disease can require specific
antimicrobial therapy based on culture. Seborrheic disease often is improved
by the use of shampoos with selenium. Allergic dermatitis can respond to
topical corticosteroid therapy.
- Conjunctivitis and keratitis can result as a complication of blepharitis
and require additional treatment besides eyelid margin therapy.
Antibiotic-corticosteroid solutions can greatly reduce inflammation and
symptoms of conjunctivitis. Corneal infiltrates also can be treated with
antibiotic-corticosteroid drops. Small marginal ulcers can be treated
empirically, but larger, paracentral, or atypical ulcers should be scraped and
specimens sent for diagnostic slides and for culture and sensitivity testing.
- Recurrent bouts of inflammation and scarring from blepharitis can promote
eyelid positional disease. Trichiasis and lid notching can result in keratitis
and severe symptoms. These conditions often are very refractory to simple
management steps. Trichiasis is treated with epilation, destruction of the
follicles via electric current, laser, or cryotherapy, or with surgical
excision. Entropion or ectropion can develop and complicate the clinical
situation and may require referral to an oculoplastics surgeon.
Surgical Care: Surgical care for blepharitis is needed only
for complications such as chalazion formation, trichiasis, ectropion, entropion,
or corneal disease.
Consultations: Patients with refractory acne rosacea may
benefit from a consultation with a dermatologist.
| |
MEDICATION |
Section 7 of 10 |
Useful medications
in the treatment of blepharitis may include topical antibiotics, topical
corticosteroids, and oral antibiotics. Typical blepharitis may be treated with a
hygiene regimen and topical antibiotic ointment. Use of combination
corticosteroid and antibiotic ointment should not be long term but may prove
useful in reduction of inflammation in difficult cases. Oral tetracyclines may
be required for refractory cases. Also, a combination antibiotic and steroid
drop may be required for associated corneal disease.
Drug Category: Topical antibiotic ointments --
Useful in targeting offending pathogens, usually Staphylococcus aureus
(and possibly other Staphylococcus, Propionibacterium, Demodex, and
Pityrosporum species, which chronically infect the lashes); the
mechanism of action seems to be reduction of staphylococcal lipase production
more than actual bacterial elimination.
Drug Name
|
Erythromycin ointment 0.5% (E-Mycin) --
Erythromycin ointment is applied to lid margins with a clean vector, such
as a cotton swab or a clean fingertip, after crusting and debris have been
removed with gentle cleansing or scrubbing.
|
| Adult Dose |
Apply a small amount (0.5-inch ribbon)
topically to the outer lid 3-4 times qd
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity to
erythromycin or ointment additives
|
| Interactions |
None reported
|
| Pregnancy |
C - Safety for use during pregnancy has
not been established.
|
| Precautions |
Do not use topical antibiotics to treat
ocular infections that may become systemic; prolonged or repeated
antibiotic therapy may result in bacterial or fungal overgrowth of
nonsusceptible organisms and may lead to a secondary infection (take
appropriate measures if superinfection occurs) |
Drug Category: Topical antibiotic/corticosteroid
suspension/ointment -- Topical corticosteroids, combined with an
antibiotic, may be useful in the short-term treatment of blepharitis to decrease
inflammation and more quickly diminish symptoms. Long-term use is not
recommended. An ointment may be used for blepharitis, while a drop may be needed
if associated corneal disease develops.
Drug Name
|
Sulfacetamide sodium and prednisolone
acetate (Blephamide) -- Sulfacetamide is an antibiotic that, like
erythromycin, has been shown to be effective against staphylococci. The
combined corticosteroid is useful in decreasing inflammation and
decreasing symptoms. Use of the 2 agents combined has been shown to
increase patient compliance. Blephamide is available in an ophthalmic
suspension and in an ointment, both containing the same concentrations of
active ingredients (10% sulfacetamide/0.2% prednisolone).
|
| Adult Dose |
Ointment: 0.5-inch ribbon topically to
affected lid(s) 3-4 times qd and once or twice at night; discontinuation
should be gradual
Drops: May be instilled 1 gtt 3-4 times qd;
gradual discontinuation is necessary
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity to any
ingredients, sulfonamides, or corticosteroids; viral, mycobacterial, and
fungal eye disease; glaucoma or ocular hypertension
|
| Interactions |
Decreases effects of silver compounds and
gentamicin
|
| Pregnancy |
C - Safety for use during pregnancy has
not been established.
|
| Precautions |
Use may cause glaucoma and posterior
subcapsular cataract formation; rarely, fatalities have occurred due to
severe reactions to sulfonamides including Stevens-Johnson syndrome, toxic
epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis,
aplastic anemia, or other blood dyscrasias
If inflammation or pain
persists longer than 48 h or becomes aggravated, the patient should
discontinue and consult a physician; consult a Physicians' Desk
Reference or package insert for further details | |
Drug Category: Oral antibiotics -- Staphylococcal
blepharitis usually responds more quickly to combined use of topical and oral
antibiotics, although a trial of topical antibiotics alone usually is indicated
before oral antibiotics should be considered. Tetracyclines are the DOC.
Drug Name
|
Tetracycline (Sumycin) -- Treats
gram-positive and gram-negative organisms as well as mycoplasmal,
chlamydial, and rickettsial infections. Inhibits bacterial protein
synthesis by binding with 30S and possibly 50S ribosomal subunit(s).
Metabolized by the liver and the kidneys. Usually not the DOC for most
staphylococcal infections but has been shown to be effective in the
treatment of refractory blepharitis, in which Staphylococcus
aureus is the usual pathogen. Tetracyclines should not be taken with
antacids or foods, but rather, they should be taken 1-2 h after meals.
|
| Adult Dose |
1-2 g PO divided bid to qid, depending on
severity, for 1-2 mo
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity; pregnant or
breastfeeding women; renal or hepatic impairment
|
| Interactions |
Bioavailability decreases with antacids
containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate;
can decrease effects of oral contraceptives, causing breakthrough bleeding
and increased risk of pregnancy; tetracyclines can increase
hypoprothrombinemic effects of anticoagulants
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Has been shown to cause yellow-gray-brown
discoloration of the teeth if used during tooth development (last one half
of pregnancy up to age 8 y); photosensitivity is common and avoidance of
the sun is essential; may cause an increase in BUN and should be avoided
in those with impaired renal function; has been linked to the development
of pseudotumor cerebri; superinfection may occur; various adverse
reactions may occur; refer to the Physicians' Desk Reference or
package insert for more complete information |
Drug Name
|
Doxycycline (Bio-Tab, Doryx, Vibramycin,
Doxy) -- Inhibits protein synthesis and thus bacterial growth by binding
to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
|
| Adult Dose |
100-200 mg PO qd; some sources recommend
using one half of initial dose during second month
|
| Pediatric Dose |
Not established
|
| Contraindications |
Documented hypersensitivity; pregnant or
breastfeeding women; renal or hepatic impairment
|
| Interactions |
Bioavailability decreases with antacids
containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate;
tetracyclines can increase hypoprothrombinemic effects of anticoagulants;
tetracyclines can decrease effects of oral contraceptives, causing
breakthrough bleeding and increased risk of pregnancy
|
| Pregnancy |
D - Unsafe in pregnancy
|
| Precautions |
Photosensitivity may occur with prolonged
exposure to sunlight or tanning equipment; reduce dose in renal
impairment; consider drug serum level determinations in prolonged therapy;
tetracycline use during tooth development (last one half of pregnancy
through age 8 y) can cause permanent discoloration of teeth; Fanconilike
syndrome may occur with outdated tetracyclines |
| |
FOLLOW-UP |
Section 8 of 10 |
Further Outpatient Care:
- Patients with blepharitis usually are started on treatment, and they are
seen in 2-6 weeks for a follow-up examination. During this visit, an
assessment of the clinical response to therapy is made. The physician should
again emphasize the necessity for a prolonged and dedicated course of
treatment to the patient. Encouragement and support is critical in helping
them to become committed to the course of treatment and to follow it.
Additionally, the clinician is able to keep the focus on rigorous intervention
by the patient, rather than accepting blame for not curing the
condition.
- Patients are seen based on progress. If little improvement has been made
after 1-2 months of treatment, intervention should be stepped-up by
prescription of antibiotic-corticosteroid ointments, oral antibiotics, or by
treating tear film dysfunction with measures such as punctal closure.
Fluorescein staining is recommended on each examination.
Deterrence/Prevention:
- Maintenance of a long-term, low-grade regimen of lid hygiene helps prevent
outbreaks of more symptomatic disease.
Complications:
- Conjunctivitis and keratitis can result as a complication of blepharitis
and require additional treatment besides eyelid margin therapy.
Antibiotic-corticosteroid solutions can greatly reduce inflammation and
symptoms of conjunctivitis. Corneal infiltrates also can be treated with
antibiotic-corticosteroid drops. Small marginal ulcers can be treated
empirically, but larger, paracentral, or atypical ulcers should be scraped and
specimens sent for diagnostic slides and for culture and sensitivity
testing.
- Recurrent bouts of inflammation and scarring from blepharitis can promote
eyelid positional disease. Trichiasis and lid notching can result in keratitis
and severe symptoms. These conditions often are very refractory to simple
management steps. Trichiasis is treated with epilation, destruction of the
follicles via electric current, laser, or cryotherapy, or with surgical
excision. Entropion or ectropion can develop and complicate the clinical
situation.
Prognosis:
- Over all, the prognosis for patients with blepharitis is good to
excellent. Blepharitis only causes significant morbidity in an extremely small
subset of patients. For most, it remains more of a symptomatic affliction than
a true threat to their health and function. Patients experience a considerable
amount of discomfort and misery that can greatly reduce their well-being and
ability to carry out the daily activities of life and work. Recognition of the
waxing and waning course of the disease, and of management through a prolonged
program rather than via an instant cure, helps them to approach the disease in
a successful manner.
| |
MISCELLANEOUS |
Section 9 of 10 |
Medical/Legal Pitfalls:
- Patients with unilateral or very asymmetric blepharitis may have sebaceous
cell carcinoma. An oculoplastics consult may be required for a lid
biopsy.
| |
BIBLIOGRAPHY |
Section 10 of 10  |
- Arky R: Acromycin V tetracycline HCl. In: Physicians' Desk Reference. 53rd
ed. 1999: 1514-1515[Full Text].
- Cohen EJ: Cornea and external disease in the new millennium. Arch
Ophthalmol 2000 Jul; 118(7): 979-81[Medline].
- Fraunfelder FT, Roy FH, Steinemann TL: Current Ocular Therapy. 5th ed.
2000: 72, 374, 378, 450.
- Held KS: Blepharitis. In: Decision Making in Ophthalmology. 2nd ed. 2000:
50-51.
- Kanski JJ: Marginal blepharitis. In: Clinical Ophthalmology. 1984;
1.2-1.4.
- Roy, FH: Ocular Differential Diagnosis. 6th ed. 2000.
- Sullivan JH: Lids and lacrimal apparatus. In: General Ophthalmology. 14th
ed. 1995: 78-81.
- Weisbecker CA, Fraunfelder FT, Rhee D: Physicians' Desk Reference for
Ophthalmology. 28th ed. 2000.
- Yanoff M, Fine BS: Inflammation. In: Ocular Pathology. 4th ed. 1996:
166-168.
| NOTE:
|
| Medicine is a constantly changing
science and not all therapies are clearly established. New research
changes drug and treatment therapies daily. The authors, editors, and
publisher of this journal have used their best efforts to provide
information that is up-to-date and accurate and is generally accepted
within medical standards at the time of publication. However, as medical
science is constantly changing and human error is always possible,
the authors, editors, and publisher or any other party involved with the
publication of this article do not warrant the information in this article
is accurate or complete, nor are they responsible for omissions or errors
in the article or for the results of using this information. The reader
should confirm the information in this article from other sources prior to
use. In particular, all drug doses, indications, and contraindications
should be confirmed in the package insert. FULL DISCLAIMER
|
eMedicine Journal,
August 2 2001, Volume 2, Number 8
Blepharitis,
Adult excerpt
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