H01.001-005 Blepharitis

Anterior blepharitis affects the anterior portion of the eyelid margin and the eyelashes.  It refers to those manifestations primarily affecting the lashes and their associated pilosebaceous glands.  Bacterial and seborrheic are the most common types of anterior blepharitis, while Demodex (mites) and acne rosacea are less common causes.

Structural Damage to the Eye

For staphylococcal and seborrheic anterior blepharitis, the conditions affect the area surrounding the base of the eyelashes.

Bacteria-associated anterior blepharitis results from bacterial overgrowth, most commonly from staphylococcus epidermis and staphylococcus aureus.  

The main goal of the diagnostic evaluation in a patient with anterior blepharitis is to accomplish the following:

1.  Stage the disease based on it’s clinical features

• Patient symptoms
• Eyelid appearance
• Ocular surface staining

2.  Relieve ocular pain and discomfort

• Prescribe a treatment program to treat the anterior blepharitis
• Prescribe a treatment program to treat any associated dry eye syndrome

Patient History

Patients may present with any or all of the following clinical signs and symptoms:

• None
• Mild ocular discomfort
• Itching
• Photophobia
• Ocular redness
• Puffy eyelids

External Ocular Examination with Biomicroscopy

• Hard scales and crusting around the base of the eyelashes
• Mild papillary conjunctivitis
• Chronic conjunctival hyperemia
• Scarring and notching of the eyelid margin
• Madarosis, trichiasis, and poliosis
• Stye formation
• Marginal keratitis
• Phlyctenulosis
• Tear film instability

		Clinical Appearance of the Eyelashes Collarettes located around the base of the eyelashes Common finding in staphylococcal anterior blepharitis
		Clinical Appearance of the Eyelashes Madarosis (loss of eyelashes) is common in severe long-standing cases of staphylococcal anterior blepharitis
		Clinical Appearance of the Palpebral Conjunctiva Mild papillary conjunctivitis is associated with chronic anterior blepharitis
		Clinical Appearance of the Bulbar Conjunctiva Chronic anterior blepharitis may cause secondary inflammatory and mechanical changes in the conjunctiva, a condition called blepharoconjunctivitis Conjunctival chemosis and hyperemia is associated with chronic anterior blepharitis
		Clinical Appearance of the Eyelid Margin Telangiectasia of the eyelid margin correlates with the presence of anterior blepharitis This is a common finding in anterior blepharitis associated with other ocular or systemic disorders (e.g., acne rosacea)

DIAGNOSTIC TESTS

External Ocular Photography

• Document clinical appearance of the eyelid margin
• Document clinical appearance of the inferior cornea
• Help to plan treatment of meibomian gland disease

Anterior blepharitis can be categorized into four subtypes:

Stapylococcal blepharitis  

• Collarettes around the base of the eyelashes 
• Mild papillary conjunctivitis
• Scarring and notching of the lid margin
• Loss of eyelashes

Seborrheic blepharitis  

• Hyperemia of the anterior lid margin
• Greasy anterior lid margin
• Sticking together of lashes
• Soft scales on the eyelashes and eyelid margin

Demodex-induced anterior blepharitis 

• Waste material from the mites is visible at the base of the eyelashes 

Acne rosacea-induced anterior blepharitis  

• Characterized by telangiectasias

There are no differential diagnoses for anterior blepharitis.

The goals of treating anterior blepharitis include the following:

• Improve patient symptoms
• Reduce chronic eyelid inflammation
• Prevent damage to the ocular surface

Mechanical Treatment

• Eyelid hygiene with lid scrubs

Palliative Treatment

• Artificial tears (non-preserved is preferred for frequent use)
• Topical emollient lubricant
• Liposomal spray
• Warm compress therapy

Pharmacologic Treatment

• Topical antibiotic gel eye drops (e.g., Azasite ophthalmic solution) 
• Topical cyclosporine eye drops (e.g., Restasis ophthalmic emulsion)
• Topical antibiotic/steroid eye drops (e.g., Tobradex ST or Zylet ophthalmic suspension) 
• Topical steroids eye drops (e.g., Lotemax gel, FML 0.1%, or Pred forte ophthalmic suspension)
• Topical steroid/antibiotic ointment (e.g., Tobradex ophthalmic ointment)
• Topical steroid ointment (e.g., Lotemax ophthalmic ointment)

1.  Stephenson M.  Blepharitis:  The Cause Guides to Treatment.  Review of Ophthalmology.  5 Sept 2013. http://www.revophth.com/content/c/42801/.  Last accessed August 17, 2014. 
2.  Stuart A.  Managing Blepharitis:  Tried-and-True and New Approaches.  American Academy of Ophthalmology. http://www.aao.org/publications/eyenet/201207/cornea.cfm.  Last accessed August 17, 2014.
3.  Lowery S.  Adult Blepharitis.  Medscape/EMedicine.  20 Feb 2014. http://emedicine.medscape.com/article/1211763-overview.  Last accessed August 17, 2014. 
4.  Kabat A. Shechtman D.  Current Therapeutic Approaches to Blepharitis Management.  RevOptom.  3 Mar 2011. http://www.revoptom.com/content/c/27049/.  Last accessed August 17, 2014.