Blepharitis

Blepharitis
Classification and external resources
An infant with mild blepharitis on his right side

Blepharitis (/blɛfərˈaɪtɨs/ blef-ər-eye-tis) is an eye condition characterized by chronic inflammation of the eyelid, the severity and time course of which can vary. Onset can be acute, resolving without treatment within 2–4 weeks (this can be greatly reduced with lid hygiene), but more generally is a long standing inflammation varying in severity. It may be classified as seborrhoeic, staphylococcal, mixed, posterior or meibomitis, or parasitic

Symptoms

Chalazion

Signs and symptoms that are associated with the chronic inflammation include:

• Redness of the eyelids
• Flaking of skin on the lids
• Crusting at the lid margins, generally worse on waking
• Infection of the eyelash follicle/sebaceous gland (hordeolum)
• Red eye
• Debris in the tear film, seen under magnification (improved contrast with use of fluorescein drops)
• Gritty sensation of the eye or foreign-body sensation
• Eye itching

The lids may become red and may have ulcerative, non-healing areas which may actually bleed.^[2] Blepharitis does not tend to cause problems with the patient's vision whatsoever, but due to a poor tear film, one may experience blurred vision.

Eye redness and swelling tend to appear in more advanced cases, and they are rarely primary symptoms. The symptoms can slightly vary based on the exact cause of the condition. Blepharitis due to an allergy can cause dark lids, a symptom which is known as "allergic shiner" and which tends to be more frequent in children rather than adults. Infectious blepharitis is accompanied by a yellow- or green-colored discharge which is more abundant in the morning and which leads to stuck lids. Blepharitis may also cause eyelid matting or "gluing" of the lashes.^{[citation needed]}

Other blepharitis symptoms include sensitivity to light, eyelashes that grow abnormally or even loss of eyelashes.^[3] Also, the tears might seem frothy or bubbly in nature and mild scarring might occur to the eyelids. The symptoms and signs of blepharitis are often erroneously ascribed by the patient as being due to "recurrent conjunctivitis".^[4]

Blepharitis that localizes in the skin of the eyelids may cause styes or chalazia, which appear like red bumps, sometimes with a yellow spot if infection is present. Although pain is not common among blepharitis symptoms, if the condition persists or becomes painful, the individual is recommended to seek medical attention.^[5]

Chronic blepharitis may result in damage of varying severity which may have a negative effect upon vision and therefore upon the eyeglass prescription.^[2]

Infectious blepharitis can cause hard crusts around the eyelashes which leave small ulcers that may bleed or ooze after cleaning.^{[citation needed]}

As a general rule, blepharitis symptoms which do not improve, despite good hygiene consisting of proper cleaning and care of the eye area, should be referred to a doctor.^{[citation needed]}

People who usually wear contact lenses may have more trouble in coping with their symptoms, because the lenses cause further irritation to the eye.^{[citation needed]}

Staphylococcal blepharitis

Staphylococcal blepharitis is caused by infection of the anterior portion of the eyelid by Staphylococcal bacteria. Patients notice a foreign body sensation, matting of the lashes, and burning. Collarette around eyelashes, a ring-like formation around the lash shaft, can be observed, which is an important sign of this condition.^[6] Other symptoms include loss of eyelashes or broken eyelashes.^[7] The condition can sometimes lead to a chalazion or a stye.^[8]

Staphylococcal blepharitis is a condition which may start in childhood and continue through adulthood.^[9] It is commonly recurrent and it requires special medical care. The prevalence of Staphylococcus aureus in the conjunctival sac and on the lid margin varies among countries, probably due to climate.^[10]

Staphylococcal blepharitis is normally treated with antibiotics such as Chloramphenicol ointment. Fusidic acid is usually the choice of antibiotics in cases when Chloramphenicol is contraindicated. Antibiotics are given for at least four to six weeks, which may be enough to completely cure the infection. A short course of topical steroids are administered to control the inflammation. The infection is only treated effectively if given at the same time with extra cautious eyelid hygiene. This consists of proper cleaning of the eyelid, removing crusts and debris.^{[citation needed]}

Posterior blepharitis or rosacea-associated blepharitis

Posterior blepharitis is inflammation of the eyelids secondary to dysfunction of the meibomian glands. Like anterior blepharitis it is a bilateral chronic condition and manifested by a broad spectrum of symptoms involving the lids including inflammation and plugging of the meibomian orifices and production of abnormal secretion upon pressure over the glands. It may be associated with skin rosacea,^[1] and there is growing evidence that in some cases it is caused by demodex mites.^[11]

Treatment and management

The single most important treatment principle is a daily routine of lid margin hygiene, as described below. Such a routine needs to be convenient enough to be continued for life to avoid relapses as blepharitis is often a chronic condition. But it can be acute, and one episode does not mean it is a lifelong condition.

A typical lid margin hygiene routine consists of four steps. The steps are more challenging to perform by visually disabled or frail patients as they require good motor skills:

1. Softening of lid margin debris and oils: Apply a warm wet compress to the lids - such as a washcloth with hot water - for about two minutes. Warm wet cloths do not stay warm for long enough but dry compress masks can be conveniently warmed in a micro-wave oven and maintain a comfortable 40C temperature for 10 minutes while the waxy oils blocking the glands are cleared. The humidity created also helps to reduce the evaporation of natural tears which are important in soothing the cornea.^[12]
2. Mechanical removal of lid margin debris: After warm compresses, wash your face with a wash cloth. Use facial soap or non-burning baby shampoo (make sure to dilute the soap solution 1/10 with water first). Gently and repeatedly rub along the lid margins while eyes are closed. Too much soap or shampoo may remove the essential oily layer of the eyes' own tear film and create further problems with dry eye discomfort. A moist cotton swab soaked in a cup of water with a drop of baby shampoo may be used to rub along the lid margins while tilting the lid outward with the other hand.
3. Antibiotic reduction of lid margin bacteria (at the discretion of a physician): After lid margin cleaning, spread small amount of prescription antibiotic ophthalmic ointment with finger tip along lid fissure while eyes closed. Use prior to bed time as opposed to in the morning to avoid blurry vision.
4. Avoid the use of eye make-up until symptoms subside.

Often the above is advised together with mild massage to mechanically empty glands located at the lid margin (Meibomian glands, Zeis glands, Moll glands).

Microbial blepharitis is treated with antibiotics such as sulfacetamide eye ointment applied on a cotton applicator once daily to the lid margins. Ophthalmologists may prescribe low-dose oral antibiotics such as Doxycycline and occasionally weak topical steroids.^[1]

Blepharitis caused by demodex mites can be treated using a diluted solution of tea tree oil and using a cotton swab for 5–10 minutes per day.^[13] It is typically necessary to continue the treatments for 4–6 weeks to eliminate the infestation.

Physicians may consider allergy testing and ocular antihistamines. Allergic responses to dust mite feces and other allergens can cause lid inflammation, ocular irritation, and dry eyes. Prescription ocular antihistamines and over-the-counter ocular antihistamines can bring relief to patients whose lid inflammation is caused by allergies.

Researchers have found Omega-3 supplementation in the form of fish oil or flaxseed to be beneficial in reducing the primary symptoms of blepharitis.^[14][15][16]

A Cochrane Systematic Review examined 34 studies, consisting of over 2,000 participants suffering from blepharitis or blepharoconjunctivitis. Topical antibiotics were shown to be effective in providing symptomatic relief and clearing bacteria for individuals with anterior blepharitis.^[17] Topical steroids provided some symptomatic relief but were ineffective in clearing bacteria from the eyelids.^[17] Lid hygiene measures such as warm compresses and lid scrubs were found to be effective in providing symptomatic relief for participants with anterior and posterior blepharitis.