Anterior Blepharitis

Anterior blepharitis is inflammation of the eyelid margin at the base of the lashes, caused by staphylococcal infection, seborrhoeic dermatitis or Demodex infestation. Bacterial toxins and hypersensitivity drive the inflammation.

• Staphylococcal blepharitis shows collarettes and ulcerated crusts; seborrhoeic blepharitis shows greasy scales.
• It is chronic, bilateral and relapsing.
• It occurs with seborrhoeic dermatitis, rosacea and atopy.

Red, itchy, burning lid margins with crusts at the lash bases on waking, lash loss, misdirected lashes, and a foreign body sensation.

• Staphylococcal disease shows hard crusts and collarettes; seborrhoeic disease shows greasy, waxy scales with oily lashes.
• Differential diagnosis: posterior blepharitis, conjunctivitis, allergic eyelid dermatitis, herpes zoster ophthalmicus, pediculosis of lashes, trichiasis, sebaceous carcinoma, impetigo, psoriasis.
• Complications: stye (hordeolum), chalazion, madarosis, trichiasis, marginal keratitis, corneal ulcer, conjunctivitis.

Clinical diagnosis at the slit lamp.

• Examination of lashes and lid margin; epilation of lashes to look for Demodex or lice.
• Culture of lid margin for recurrent or severe disease.
• Biopsy for lid lesions with lash loss and mass.

Daily lid hygiene is the foundation of treatment.

• Supportive: warm compresses for 5 to 10 minutes, then lid scrubs with a cotton bud and diluted baby shampoo (one part to ten parts boiled water) or commercial lid wipes, twice daily for 2 weeks and then daily; stop eye make up; wash face and hair with an anti dandruff shampoo for seborrhoea.
• Pharmacological: fusidic acid 1 percent gel or chloramphenicol 1 percent ointment applied to the lid margin twice daily for 4 to 6 weeks; erythromycin 0.5 percent ointment as an alternative; azithromycin 1 percent drops twice daily for 3 days then daily for 4 weeks; oral doxycycline 100 mg daily for 4 to 8 weeks for refractory disease; preservative free lubricants for dry eye; short course of mild steroid drops under ophthalmology care for marginal keratitis.
• Procedures: lash epilation for trichiasis; removal of collarettes at the slit lamp.
• Special groups: pregnancy and children under 8 years, avoid doxycycline and use topical therapy; atopy, treat dermatitis; seborrhoeic dermatitis, ketoconazole 2 percent shampoo.
• Red flags: loss of vision, corneal ulcer, lid mass, unilateral lash loss, painful red eye.
• Follow-up: review at 4 to 6 weeks; the condition is chronic and the lid hygiene must continue.