Blepharitis

Blepharitis is chronic inflammation of the eyelid margin, one of the commonest external eye diseases, causing relapsing, usually bilateral symptoms. It is not curable, and long term management is required.

• Anterior blepharitis (lashes and follicle area): staphylococcal (Staphylococcus aureus and epidermidis; hard brittle collarettes and lid margin ulceration), seborrhoeic (scaly greasy flakes with seborrhoeic dermatitis), and Demodex (Demodex folliculorum infestation producing cylindrical collarettes at the lash base).
• Posterior blepharitis: meibomian gland dysfunction with obstruction, inspissated secretions, glandular drop out, and altered lipid; associated with rosacea, atopic disease, and seborrhoeic dermatitis.
• Mixed disease is common, and all forms contribute to dry eye.

• Burning, itching, grittiness, redness of the lid margins, crusting on waking, flaking, sticky lashes, and tearing.
• Signs: lid margin erythema, telangiectasia, scales and collarettes, misdirected or lost lashes (madarosis), trichiasis, poliosis, notching, thickened or capped meibomian gland orifices, frothy or toothpaste like secretions, and foam at the lid margin.
• Associated: recurrent chalazia and hordeola, marginal keratitis, phlyctenulosis, conjunctival hyperaemia, inferior punctate keratopathy, tear film instability, and neovascularisation.
• Rosacea: facial flushing, telangiectasia, papules, and rhinophyma, with ocular involvement including corneal vascularisation and perforation.

• Clinical, with slit lamp evaluation of the lid margin, lashes, meibomian gland expression, tear break up time, and corneal staining.
• Microscopy of epilated lashes for Demodex (more than 3 mites per lash is abnormal).
• Swabs for culture only in recurrent disease unresponsive to treatment. Biopsy of chronic unilateral asymmetrical or recurrent disease with madarosis or loss of lashes to exclude sebaceous gland carcinoma, basal cell carcinoma, and other tumours.
• Skin examination for rosacea and seborrhoeic dermatitis.

• Lid hygiene is the foundation and must be continued indefinitely: warm compresses (a heated cloth or mask) for 5 to 10 minutes once or twice daily, followed by gentle lid massage and lid margin cleaning with diluted baby shampoo, commercial hypochlorous acid 0.01 percent lid spray, or lid scrub wipes.
• Artificial tears (preservative free) for dry eye symptoms; omega-3 supplements for meibomian gland disease.
• Anterior staphylococcal blepharitis: topical antibiotic ointment to the lid margin at night for 2 to 4 weeks (erythromycin 0.5 percent, fusidic acid 1 percent gel, or chloramphenicol 1 percent ointment), or topical azithromycin 1.5 percent drops twice daily for 2 days then once daily for 12 days.
• Posterior blepharitis and meibomian gland dysfunction: oral doxycycline 100 mg daily or twice daily for 2 weeks and then 50 mg to 100 mg daily for 2 to 3 months (avoid in pregnancy, breastfeeding, and children under 8 years); alternatives are oral azithromycin 500 mg daily for 3 days repeated monthly for 3 cycles, or erythromycin 250 mg twice daily for children and pregnancy. Add in office thermal pulsation, intense pulsed light, or lid debridement.
• Demodex blepharitis: lotilaner 0.25 percent ophthalmic solution 1 drop to each eye twice daily for 6 weeks; or 50 percent tea tree oil lid treatment in the office with 5 percent tea tree oil scrubs at home; oral ivermectin 200 micrograms/kg single dose, repeated at 1 week in some centres.
• Inflammation flares and marginal keratitis: topical corticosteroid, loteprednol 0.5 percent or fluorometholone 0.1 percent twice to four times daily for 1 to 2 weeks (only short courses).
• Treat associated rosacea (oral doxycycline 40 mg modified release daily or 100 mg daily, topical metronidazole 0.75 percent or azelaic acid 15 percent to the face) and seborrhoeic dermatitis (ketoconazole 2 percent shampoo or topical imidazole).
• Recurrent chalazia: incise and curette and reinforce lid hygiene.
• Follow up: 4 to 6 weeks after starting treatment and every 3 to 6 months afterwards. Counsel patients that symptoms recur if hygiene is stopped.
• Complications: chalazia, hordeola, madarosis, lid notching and trichiasis, corneal ulceration, vascularisation, and persistent dry eye.