Mahmood
J Showail
 Blepharitis
is inflammation or infection of
the eyelid margins .
 it is one the most common ophthalmological
complications as well as one of the most
difficult conditions to treat.
I will discuss blepharitis according to its
predominant anatomic location, as anterior
or posterior.
1. Anterior
Staphylococcal•
Seborrhoeic•
2. Posterior
Meibomianitis•
Meibomian seborrhoea•
 Anterior
blepharitis is characterized by
inflammation at the base of the eyelashes .
Patients with anterior blepharitis, compared
to those with posterior blepharitis, are more
likely to be female and younger *
* McCulley, JP, Dougherty, JM, Deneau, DG. Classification of chronic
blepharitis. Ophthalmology 1982; 89:1173.
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.
The pathophysiology of blepharitis is not completely
understood. A role for lid-colonizing staphylococcal
bacteria was first noted in 1946 . Several mechanisms
by which staphylococci may alter meibomian gland
secretion and cause blepharitis are supported by
many studies .



Direct infection of the lids
Evoke reaction to staphylococcal exotoxin
Provoke allergic response to staphylococcal antigens .

It is likely that a combination of these is responsible
for the clinical manifestations of staphylococcal
blepharitis.
symptoms
burning , grittiness and mild photophobia
with remission and exacerbation is
characteristic .
 Symptoms are usually worse in the morning ,
although in patients with dry eye they may
increase during the day .


note : because of poor correlation between
the severity of symtpmos and clinical signs it
can be difficult to objectivley assess the
benefit of treatment .
A. Staphylococcal blepharitis
 Hard scales and crusing mainly located
around the bases of the lashes esp.
collorette
 chronic conjunctival hyperemia with mild
papillary conjunctivitis .
Staphylococcal blepharitis
Chronic irritation worse in morning•
Scales around base of lashes •
(collarettes)
Hyperaemia and telangiectasia of •
anterior lid margin
Scarring and hypertrophy if •
longstanding
 scarring
and notching (tylosis) of the lid
margin , trichiasis (misdirected eyelashes),
madarosis (loss of lashes) or poliosis (loss of
pigmentation of lashes) in sever long
standing cases

secondary changes include stye formation ,
marginal keratitis and occasionally
phlyctenulosis (Corneal nodulesthat
developed near the limbus and then spread
onto the cornea, carrying behind them a
leash of vessels) .

associated with tear film instability and dry
eye .
 Hyperemic
and greasy anterior lid margin
with sticking together of lashes
 the scales are mainly scruf , and located any
where on the lid margin and lashes .
Seborrhoeic blepharitis
Shiny anterior lid margin•
Hyperaemia of lid margin•
Greasy scales •
Lashes stuck together•

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 .
 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).

There is little evidence to support any
particular protocol for anterior blepharitis .

Patient should be advised that lifelong
treatment may be necessary and that
permenent cure is unlikely . But control of
symptoms is usually possible .
Lid hygiene
1.
•
warm compresses applied for several minutes
to soften crusts at the bases of the lashes .
•
Lid cleaning to mechanically remove crusts
involve scrubbing of the lid margins once or
twice daily with a cotton dipped in a dilute
solution of baby shampoo or NaHCO3 .
•
Commercially produced soap/alcohol
impregnated pads for lids scrubs are available .
2.Antibiotics
*Topical

sodium fucidic acid , bicarbonate or
chlormaphinicol : used to treat acute folliculitits
but is of limited value for long standing cases

Azithromycin (500mg daily for 3 days ) may be
helpful to control ulcerative lid margin disease .
*Oral
3. Weak topical steroids
Such as flurometholone 0.1 % QID for 1 week
is usful for patients with sever papillary
conjunctivitis , marginal keratitis and
phlyctenulosis .
4. Tear substitutes
Required for associted tear film instability and
dryness

Posterior blepharitis, the more common
condition, is characterized by inflammation
of the inner portion of the eyelid, at the
level of the meibomian glands . It is often
described as meibomian gland dysfunction.

MG are modified sebaceous glands located within
the tarsal plates . These holocrine glands are
responsible for secretion of the oily layer of the
tear film.
This oily layer prevents tear evaporation and
reduces the surface tension of the tear layer,
thereby facilitating the spread of tears over the
ocular surface . It is critical for normal ocular
surface lubrication.

Posterior blepharitis is caused by meibomian
gland dysfunction and alteration in miebomian
gland secretion .
 Bacterial
lipase may result in the formation
of free fatty acid . This increase in the
melting point of meibum preventing its
expression from the glands, contributing to
occular surface irritation and possibly
enabling growth of S. aureus .
 Loss
of the tear film phospholipid that act as
a surfactant result in increased tear
evaporation and unstable tear film .

there is poor correlation between severity of
symptoms and the clinical signs .
symptoms :
Similar to anterior blepharitis
 Signs :


* Excessive and abnormal meibomian gland
secretion which may manifest as capping of
meibomian gland orifices with oil globule .

pouting, recession or pulgging of the
meibomian gland orifices with hyperemia and
telangictasis of the posterior lid margin
Inflamed and blocked
meibomian gland orifices
Plugging of meibomian gland orifices

pressure on the lid margin result in
expression of meibomian fliud that may be
turbid or appear like tooth paste . In sever
cases the secretions become so inspissated
that expression is impossible .
Toothpaste-like plaques
from meibomian glands

the tear film is oily and
foamy and froth may
accumelate on the lid
margin or inner canthi .
Oily and foamy tear film
Foam in meibomian seborreha

Chalazion
Which maybe multiple and recurrent , is common
particularly in patient with posterior blepharitis .
 Tear
film instability and dry eye
Is found in 30-50% of patients probably as aresult
of imbalance between the aques and lipid
components of the tear film allowing evaporation
. Tear film break up tim eis typically reduced .
 Epithelial
basement membrane defects
Cutaneous




acne rosacea is often ass. With MGD
Seborrhoeic dermatitis is present >90% of
patients with seborrhoeic blepharitis
Acne vulgaris : due to treatment with isoretinoin
 Contact

lens intolerance
Long-term contact lens wear is associated with
posterior lid margin disease .
 posterior
blepharitis is often found in
association with skin conditions such as
rosacea and seborrheic dermatitis .

Rosacea is associated with plugging and
hypertrophy of the sebaceous glands. Since the
meibomian glands are modified sebaceous
glands, rosacea may lead directly to meibomian
dysfunction .

Seborrheic dermatitis is also associated with
inflammation of the meibomian glands.

Its very important to tell the patient that
cure is unlikely although remession may be
achived .
1.Lid hygine
As in anterior blepharitis with emphasis on
messaging the lid to express acumilated
meibum, the messaging is toward the lid
margin edge to “milk” meibum .
2. Systemic tetracycline



Are the mainstay of treatment .
It is used mainly to block staphylococcal lipase
production .
It is particularly idicated in patients with recurrent
phlyctenulosis and margina keratitis .
Note , tetracycline sohuld not be used in
Children less than 12 yrs
 Pregnant women
 Lactating women
due to “ staining of bone and teeth & dental hypoplasia

Types of tetracycline :
Oxytetracycline : 250mg BD for 6-12 wks
 Doxycycline : 100mg BD for1wk then daily for
6-12 wks
 Minocycline : 100mg daily for 6-12 wks
 Erythromycine : 250 mg daily or BD “ may be
used in children “

3. Topical glucocorticoids
There may be a role for topical glucocorticoid
use in the short term treatment of acute
blepharitis exacerbations. Patients should
generally be evaluated by an ophthalmologist
prior to its initiation “ to adjust benefit VS
S/E “
4. Topical 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 , and improved clinical
findings in patients with posterior blepharitis
[1,2].
 Its has a high cost , so it should be reserved to
refractory cases only .

(1) Rubin, M, Rao, SN. Efficacy of topical cyclosporin 0.05% in the treatment of
posterior blepharitis. J Ocul Pharmacol Ther 2006; 22:47.
(2) Perry, HD, Doshi-Carnevale, S, Donnenfeld, ED, et al. Efficacy of commercially
available topical cyclosporine A 0.05% in the treatment of meibomian gland
dysfunction. Cornea 2006; 25:171.
 Several
topical medications are under
evaluation as treatment for blepharitis.
Topical metronidazole is a potential
substitute for the use of systemic antibiotics,
especially in cases of blepharitis related to
rosacea *
Cohen, EJ. Cornea and external disease in the new millennium. Arch
Ophthalmol 2000; 118:979.
 Topical
tacrolimus ointment has been
used to treat severe refractory blepharitis
with good results (1)
 Development
of effective tear lipid
substitutes may palliate the symptoms of
blepharitis (2)
1 . Joseph, MA, Kaufman, HE, Insler, M. Topical tacrolimus ointment
for treatment of refractory anterior segment inflammatory
disorders. Cornea 2005; 24:417.
2. McCulley, JP, Shine, WE. Changing concepts in the diagnosis and
management of blepharitis. Cornea 2000; 19:650.
 Allergic
blepharitis —
Allergic blepharitis is an acute inflammatory
reaction of the skin of the eyelids, usually
occurring as a reaction to a contact irritant . 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 . Although this parasite can cause
some changes in the eyelash follicles esp. sleave
scales , but still there is no evidence that it is
directly associated with blepharitis
Picture
demonstrating
thinning of eyelids
secondary to
corticosteroid use.
Note sleeves and
scurf
Sebacous gland carcinoma
—
Blepharitis is nearly always bilateral.
A malignant tumor of the lid skin
(ie, sebaceous cell carcinoma) should be
suspected in a patient with persistent
unilateral eyelid inflammation
 Other
symptoms of malignancy include
failure to respond to treatment, a nodular
mass, ulceration, extensive scarring, or
conjunctival nodules surrounded by
inflammation
www.UptoDate.com
 Ophthalmology Hyper guide
 Kanski, Clininal Ophthalmology
