Bacterial Blepharitis

Bacterial blepharitis is infection and inflammation of the lid margin, usually by Staphylococcus aureus or coagulase negative staphylococci. Bacterial toxins, lipases and hypersensitivity to antigens cause chronic inflammation.

• It often coexists with posterior blepharitis and seborrhoeic dermatitis.
• Diabetes, dry eye and contact lens wear are risk factors.
• It is a common cause of recurrent styes and marginal keratitis.

Red, swollen lid margins, matted lashes, hard crusts and collarettes, burning, itching, recurrent styes, and lashes that fall out or turn in.

• The eyes may be sticky on waking.
• Differential diagnosis: seborrhoeic blepharitis, Demodex blepharitis, posterior blepharitis, impetigo, herpes zoster ophthalmicus, allergic lid eczema, trichiasis, chalazion, preseptal cellulitis.
• Complications: hordeolum, chalazion, marginal keratitis and ulcers, phlyctenulosis, conjunctivitis, lash loss, trichiasis, corneal scarring, preseptal cellulitis.

Clinical diagnosis at the slit lamp.

• Culture of lid margin swab in recurrent or resistant disease, with susceptibility.
• Blood glucose in recurrent styes.
• Fluorescein staining of the cornea for marginal keratitis.

Lid hygiene plus topical antibiotics for flares.

• Supportive: warm compresses for 10 minutes twice daily, lid scrubs with diluted baby shampoo or lid wipes, avoid eye make up and contact lenses during flares, treat seborrhoea, wash towels and pillowcases frequently.
• Pharmacological: chloramphenicol 1 percent ointment or fusidic acid 1 percent gel applied to the lid margin twice daily for 4 to 6 weeks; erythromycin 0.5 percent ointment as alternative; azithromycin 1 percent drops twice daily for 3 days then daily for 4 weeks; oral flucloxacillin 500 mg four times daily for 7 days for preseptal cellulitis or marked disease; oral doxycycline 100 mg daily for 4 to 8 weeks for chronic disease; lubricants; combined antibiotic and steroid ointment for marginal keratitis under ophthalmology care for 1 to 2 weeks.
• Procedures: incision and curettage of persistent chalazion; epilation of misdirected lashes.
• Special groups: pregnancy and children under 8 years, avoid doxycycline and use erythromycin or azithromycin; diabetes, glucose control; MRSA, topical mupirocin or chloramphenicol and culture guided therapy.
• Red flags: eyelid swelling with fever, loss of vision, corneal ulcer, severe pain, spreading redness, orbital signs.
• Follow-up: review at 2 to 4 weeks; lid hygiene continues long term.