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Blepharitis Symptoms, Diagnosis, Treatment

Blepharitis Symptoms/Blepharitis is an ophthalmologic condition characterized by an inflammation of the eyelid margins. It can be acute or chronic with chronic being the more common form. It can further be defined by the location of the problem, anterior versus posterior. It usually presents with recurrent symptoms that may vary over time and involve both eyes. Blepharitis is a clinical diagnosis based on irritation of the lid margins with flaking and crusting of the lashes. The main treatment for blepharitis is good eyelid hygiene and elimination of triggers that exacerbate symptoms. Topical antibiotics may be prescribed. Patients refractory to these measures require referral to an ophthalmologist. The goal of treatment is to alleviate symptoms. Because most blepharitis is chronic, patients need to maintain a good hygiene regimen to prevent recurrences. While there is no definitive cure, the prognosis for blepharitis is good. Blepharitis is a more symptomatic condition than a true health threat.[rx][rx][rx][rx]

Phthiriasis palpebrarum also called phthiriasis ciliaris, or ciliary phthiriasis is an ectoparasitosis of the eyelashes due to an infestation with Pthirus pubis (sometimes written Phthirus pubis), also known as pubic louse or crab louse.[rx][rx][rx]

Blepharitis Symptoms

Types of Blepharitis

Anterior/mixed infectious and seborrheic blepharitis

Affects base of eyelashes
Associated with staphylococcal infection or Seborrhea
The role of Staphylococcus and Moraxella strains and the resulting cell-mediated inflammatory response in bacterial blepharitis has been evaluated by a number of studies.^[rx^–^[rz]
However, the meta-analysis performed by Lindsley et al evaluating topical antibiotic and topical steroid regimens in the treatment of blepharitis failed to show clinically significant improvements for either modality.
Although a majority of the reviewed studies did show significantly decreased ocular surface bacterial cultures using antibiotic therapy, these improvements were not correlated with clinical improvement of blepharitis.^[rx]

Posterior blepharitis/MGD

Affects meibomian gland openings
Associated with meibomian gland dysfunction
In the treatment of ocular surface disease secondary to posterior blepharitis, topical azithromycin has been demonstrated to improve patient signs and symptoms.^[rx]
Topical 1% azithromycin solution in combination with hyperthermic lid therapy was found to have increased effects when compared against hyperthermic lid therapy.^[rx]

According to severity

Acute blepharitis – also referred to as lid infection, may be bacterial, viral, or parasitic in etiology.^[rx] acute blepharitis can also be broken into acute ulcerative (often secondary to staphylococcal or herpetic infection) and acute nonulcerative (typically allergic).

Chronic blepharitis – that encompasses lid inflammation. Early classification work categorized chronic blepharitis into six entities:

1) staphylococcal
2) seborrheic
3) staphylococcal/seborrheic;
4) meibomian seborrhea;
5) secondary meibomian inflammation; and
6) meibomian keratoconjunctivitis.^[rx]

Causes of Blepharitis

The exact cause of blepharitis isn’t clear. It may be associated with one or more factors, including:

Seborrheic dermatitis — dandruff of the scalp and eyebrows
A bacterial infection
Clogged or malfunctioning oil glands in your eyelids
Rosacea — a skin condition characterized by facial redness
Allergies – including allergic reactions to eye medications, contact lens solutions or eye makeup
Eyelash mites or lice
Bacterial eyelid infection
Meibomian gland dysfunction (MGD)
Dry eyes
Fungal eyelid infection
Parasites (Demodex eyelash mites)
Blepharitis and dry eyes often occur at the same time, causing confusion whether dry eye causes blepharitis or blepharitis causes dry eye.

Symptoms of Blepharitis

Blepharitis Symptoms

Inflammation of Eyelid margin at the lash follicles
Moderate lid swelling along lash line
Lower Eyelid is usually more affected
Soft, oily Yellow SkinScaling
Pruritus
Local irritation and burning
Watery eyes
Red eyes
A gritty, burning or stinging sensation in the eyes
Eyelids that appear greasy
Itchy eyelids
Red, swollen eyelids
Flaking of the skin around the eyes
Crusted eyelashes upon awakening
Eyelid sticking
More frequent blinking
Sensitivity to light
Eyelashes that grow abnormally (misdirected eyelashes)
Loss of eyelashes

Associated Symptoms

Watery eyes – due to excessive tearing.^[rx]
Red eyes – due to dilated blood vessels on the sclera.^[rx]
Swollen eyelids – due to inflammation.^[rx]
Crusting – at the eyelid margins/base of the eyelashes/medial canthus, generally worse on waking – due to excessive bacterial buildup along the lid margins.^[rx]^[rx]^[rx]
Eyelid sticking – due to crusting along the eyelid margin.^[rx]
Eyelid itching – due to the irritation from inflammation and epidermis scaling of the eyelid.^[rx]
Flaking of skin on eyelids – due to tear film suppressed by clogged meibomian glands.^[rx]
Gritty/burning sensation – in the eye, or foreign-body sensation – due to crusting from bacteria and clogged oil glands^[rx]
Frequent blinking – due to impaired tear film from clogged oil glands unable to keep tears from evaporating.^[rx]
Light sensitivity/photophobia^[rx]^[rx]
Misdirected eyelashes that grow abnormally – due to permanent damage to the eyelid margin^[rx]
Eyelash loss – due to excessive buildup of bacteria along the base of the eyelashes.^[rx]
Infection of the eyelash follicle/sebaceous gland (hordeolum)
Debris in the tear film, seen under magnification (improved contrast with use of fluorescein drops)

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Diagnosis of Blepharitis

Blepharitis can be diagnosed through a comprehensive eye examination. Testing, with special emphasis on the eyelids and front surface of the eyeball, may include:

Patient history to determine any symptoms the patient is experiencing and any general health problems that may be contributing to the eye problem.
External examination of the eye, including lid structure, skin texture and eyelash appearance.
Evaluation of the lid margins, base of the eyelashes and meibomian gland openings using bright light and magnification.
Evaluation of the quantity and quality of tears to check for any abnormalities.
Staphyloccal blepharitis – patients frequently exhibit mildly sticking eyelids, thickened lid margins, and missing and misdirected eyelashes.
Seborrheic blepharitis – patients have greasy flakes or scales around the base of eyelashes and a mild redness of the eyelids.
Ulcerative blepharitis – patients have matted, hard crusts around the eyelashes. Removing the crusts leaves small sores that ooze and bleed. These patients may also experience eyelash loss, distortion of the front edges of the eyelids and chronic tearing. In severe cases, the cornea (the transparent front covering of the eyeball) becomes inflamed.
Meibomian blepharitis – patients have a blockage of the oil glands in the eyelids, poor quality of tears and redness of the lining of the eyelids.

Common differential diagnoses of blepharitis based on clinical presentation and potential underlying etiology

Differential diagnoses of blepharitis presentation
Clinical condition	Etiology
Bacterial infection	Impetigo
Bacterial infection	Erysipelas
Viral infection	Herpes simplex virus
	Molluscum contagiosum
	Vaccinia
Parasitic infection	Pthirus pubis
Parasitic infection	Demodex
Immune response related	Atopic dermatitis
	Contact dermatitis
	Erythema multiforme
	Ocular pemphigoid
Dermatoses	Psoriasis
Dermatoses	Ichthyosis
Benign lid tumors	Pyogenic granuloma
	Sebaceous cell hyperplasia
	Actinic keratosis
	Hemangioma
Malignant lid tumors	Sebaceous carcinoma
	Squamous cell carcinoma
	Melanoma
	Mycosis
Trauma	Chemical
	Thermal
	Mechanical
Toxic	Medicamentosa

Differential Diagnoses

Fact	Explanation
Chalazion	This is a common painless condition in which an obstructed meibomian gland causes a granuloma within the tarsal plate. Symptoms are of an unsightly lid swelling which usually resolves within 6 months. No itching or scaling like in blepharitis.[1]
stye	A stye (external hordeolum) is a painful abscess of an eyelash follicle. Swelling is localized than blepharitis. And there is no itching, scaling of the eye lid.[1]
Phthiriasis palpebrarum	Phthiriasis palpebrarum (PP) is an eyelid infestation caused by phthirus pubis or crab lice. main symptom is itching of eyelids.Examination findings sre similar to exfoliative lesions and color changes in eyelids and to excretions over eyelashes. Careful observation needed to reveal lice and translucent nits. Slit-lamp examination will be helpful to find lice.[2]
Molluscum contagiosum	This umbilicated lesion found on the lid margin is caused by the pox virus. It causes irritation of the eye. The eye is red and small elevations of lymphoid tissue (follicles) are found on the tarsal conjunctiva. But there is no itching, scaling, or lid edema as in blepharitis.[1]
Conjunctivitis	In conjunctivitis there is inflamed,injected conjunctiva, red eye, and excessive tearing from the aye. in bacterial conjunctivitis there may also purulent discharge than other types. there is no eye lid swelling, scalling oe meibomian glannd dysfunction like in blepharitis.[1]
Dermatitis	Usually present with pruritus, are erythematous, exudative skin leisons of the antecubital and/or popliteal skin, eyelids, There is also involment of corners of the mouth, neck, outer canthi, or behind the ears, face and extensors surfaces. There are physcial findings of the blepaharitis as well, since blepharitis is a associated condition.[1]
Roscea	Blepaharitis is a associated condition in roscea, In roscea there is also hyperaemia and telangiectasia of the facial skin and a rhinophima (swelling of the nose[1]
Keratitis	Patients with keratitis present with rapid onset of pain, photophobia, and decreased vision. patient may also give a history of contact lens use, trauma to eye. on examination there wirll be ulceration of the coneal epithelium Folds in the Descemet membrane, Upper eyelid edema. But there is no itching, scalling of the eye lid like in blepaharitis.

Treatments of Blepharitis

Eye lid hygiene – Initial treatment is eyelid hygiene, it has three components,warm compresses, eyelid massage, and eyelid scrub.Warm compresses should be done for at least 5 minutes, followed by lid massage at least once daily. The warm compresses help to melt the altered secretions of the meibomian glands. Eyelidmassage, this is compressing the eye lid against the eye balll, it helps to milk excess secretions from the meibomian glands. By eye lid scrub, eyelid margin is washed mechanically and clean the gland orifices which consist of gently scrubbing the eyelids with a wet washcloth. This is performed after the warm compresses.
Artificial tears – The tear film in patients with blepharitis is abnormal, and artificial tears may provide considerable relief of symptoms
Topical antibioics – Topical antibiotics are used to treat both Staphylococcal and seborrheic blepharitis, preferably in ointment form, They are applied usually at bed time. It is smeared on the lid margin to reduce the staphylococci flora in the lid.This treatment is required for several month to have a reasonable response. Ointment is applied after lid hygiene are done. Treatment regimen would be once or twice daily depending on the severity of the inflammation .Commonly used antibiotics are fusidic acid gel, erythromycin and bacitracin. Antibiotic therapy may be discontinued in two to eight weeks or once symptoms resolve.But in some patients with severe disease . treatment will require for long duration to keep the patient symptom free.
Several topical treatments may be used in phthiriasis palpebrarum – Yellow mercuric oxide ophthalmic ointment (older publications), parasympathomimetic agents (physostigmine, pilocarpine), 20% fluorescein, and liquid petrolatum ointment have been reported to be efficient on lice and nits. Topical antiparasitic agents such as natural pyrethrins, pyrethroids, malathion, and lindane (sometimes erroneously reported as gamma-benzene hexachloride) may also be prescribed.
Topical antiseptics – Bibrocathol is a antiseptic drug for the treatment of acute eyelid diseases.Eye ointments containing 2 or 5 % bibrocathol are used to treat bleparitis.
Topical steroids – Topical steroids may improve an anterior blepharitis but frequent use is best avoided[4] All forms of blepharitis may benefit from a course of treatment with topical corticosteroid drops to decrease inflammation in an acute exacerbation. Should applying drops several times daily, tapered to discontinuation over one to three weeks as it have significant adverse effects over the long-term such as increased intraocular pressure (IOP), posterior subcapsular cataract formation, and superinfection. For this reason they are not recommended for long-term use
Oral antibiotics – In patients with posterior blepharitis oral tetracycline or doxycyclinemay is effective
Medications that affect the immune system – Topical cyclosporine (Restasis) is a calcineurin inhibitor that has been shown to offer relief of some signs and symptoms of blepharitis.
Treatments for underlying conditions – Blepharitis caused by seborrheic dermatitis, rosacea or other diseases may be controlled by treating the underlying disease.
Steroid eyedrops/ointments – Eye drops or ointments containing corticosteroids are frequently used in conjunction with antibiotics and can reduce eyelid inflammation.^[rx]^[rx]^[rx]
Hypochlorous acid products – Both over-the-counter and prescription products with hypochlorous acid (HOCl) can be used to alleviate the signs and symptoms of blepharitis. In a recent study, a saline hygiene solution with hypochlorous acid was shown to reduce the bacterial load significantly without altering the diversity of bacterial species on the eyelids. After 20 minutes of treatment, there was >99% reduction of the Staphylococci bacteria, which is a common cause of blepharitis.^[rx]
Cryotherapy – with liquid nitrogen performed under the slit lamp was reported to be efficient by some authors. Some authors have proposed argon laser therapy as an effective treatment for phthiriasis palpebrarum. One session using a 200-micron beam, with duration of 0.1 seconds, and a power of 0.2 W allowed the destruction of both lice and nits. However, this device necessitates a strict eye protection and may not be available on a large scale.
Oral ivermectin – may be used as a single dose treatment; however, a second dose may be necessary after seven to 10 days to control newly hatched nits. Oral ivermectin is contraindicated in children younger than five years old and/or weighing less than 15 kilograms, as well as in pregnant and lactating women. Treatment of associated body hair infestation, using antiparasitic topical and/or shaving is mandatory.
Clothing, bedding including pillowcases – and towels should be washed at 50 C for half an hour and then heat dried for up to 10 minutes to eliminate both lice and nits. All sexual contacts and family members of a person having phthiriasis palpebrarum should be evaluated for the presence of phthiriasis pubis and phthiriasis palpebrarum, and if necessary, they have to be treated. The effect of such measures in preventing recontamination has been proven.
Warm compress – Using a warm compress simply means placing a warm cloth over closed eyelids, reheating the compress with warm water when it cools and reapplying for up to 10 minutes. Dipping the cloth in warm water: Some patients have suffered facial burns by using a microwave to heat up the wet cloth. Using a soft cloth only: Scrubbing too vigorously or using a rough cloth can damage the skin and eyes. After applying a warm compress for up to 10 minutes, cleanse the eyelids.
Warming eye masks –These may achieve the same effects as the warm cloth compresses, and they may be more convenient. Eyelid cleansers are also available and offer an alternative to the use of dilute baby shampoo.
Cleanse the eyelids – To do this, gently rub the margin of the eyelid—at the base of the eyelashes, and where the glands are located—with a cotton swab soaked in a dilute solution of baby shampoo. Use 2 to 3 drops in about half a cup of warm water. This lid hygiene needs to be maintained as a self-care regime twice a day every day. This is a considerable lifelong commitment, but the symptoms will come back without it.
How to massage the eyes – After using the warm compress to loosen the sebum, massaging helps express the oily contents of the glands. With a finger or a cotton-tipped applicator or swab, massage the margin of the eyelid, where the eyelashes and glands are, using small circular motions.
Diet – There’s some evidence to suggest a diet high in omega-3 fats can help improve blepharitis.

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The best sources of omega-3s are oily fish, such as:

mackerel
salmon
sardines
herring
fresh or frozen tuna – not canned, as the canning process sometimes removes the beneficial oils

Aim to eat at least two portions of fish a week, one of which should be oily fish. You can also get omega-3s from various nuts and seeds, vegetable oils, soya and soya products, and green leafy vegetables. Omega 7 or sea buckthorn oil has also been found to be helpful.

Complications

If you have blepharitis, you may also experience

Eyelash problems – Blepharitis can cause your eyelashes to fall out or grow abnormally (misdirected eyelashes).
Eyelid skin problems – Scarring may occur on your eyelids in response to long-term blepharitis. Or the eyelid edges may turn inward or outward.
Excess tearing or dry eyes – Abnormal oily secretions and other debris shed from the eyelids, such as flaking associated with dandruff, can accumulate in your tear film — the water, oil and mucus solution that forms tears. Abnormal tear film interferes with the healthy lubrication of your eyelids. This can irritate your eyes and cause symptoms of dry eyes or excess tearing.
Difficulty wearing contact lenses – Because blepharitis can affect the amount of lubrication in your eyes, wearing contact lenses may be uncomfortable.
Sty – A sty is an infection that develops near the base of the eyelashes. The result is a painful lump on the edge (usually on the outside part) of your eyelid. A sty is usually most visible on the surface of the eyelid.
Chalazion – A chalazion occurs when there’s a blockage in one of the small oil glands at the margin of the eyelid, just behind the eyelashes. The gland can become infected with bacteria, which causes a red, swollen eyelid. Unlike a sty, a chalazion tends to be most prominent on the inside of the eyelid.
Chronic pink eye – Blepharitis can lead to recurrent bouts of pink eye (conjunctivitis).
Injury to the cornea – Constant irritation from inflamed eyelids or misdirected eyelashes may cause a sore (ulcer) to develop on your cornea. Insufficient tearing could predispose you to a corneal infection.