emedicine.medscape.

com

eMedicine Specialties > Ophthalmology > Lid

Blepharitis, Adult
R Scott Lowery, MD, Assistant Professor of Ophthalmology, Department of Pediatric
Ophthalmology and Strabismus, University of Arkansas for Medical Center, Arkansas Children's
Hospital
Updated: Jul 30, 2009

Introduction
Background
Blepharitis refers to a family of inflammatory disease processes of the eyelid(s).
Blepharitis can be divided anatomically into anterior and posterior blepharitis. Anterior
blepharitis refers to inflammation mainly centered around the eyelashes and follicles, while the
posterior variant involves the meibomian gland orifices. Anterior blepharitis usually is
subdivided further into staphylococcal and seborrheic variants.
Frequently, a considerable overlap exists in these processes in individual patients. Blepharitis
often is associated with systemic diseases, such as rosacea and seborrheic dermatitis, as well as
ocular diseases, such as dry eye syndromes, chalazion, trichiasis, conjunctivitis, and keratitis.

Pathophysiology
The pathophysiology of blepharitis usually involves bacterial colonization of the eyelids. This
results in direct microbial invasion of tissues, immune systemmediated damage, or damage
caused by the production of bacterial toxins, waste products, and enzymes. Colonization of the
lid margin is increased in the presence of seborrheic dermatitis or meibomian gland dysfunction.

Frequency

United States
Blepharitis is a common eye disorder in the United States and throughout the world.

Mortality/Morbidity
The exact association between blepharitis and mortality is not known, but diseases with known
mortality, such as systemic lupus erythematosus, may have blepharitis as part of their
constellation of findings. Associated morbidity includes loss of visual function, well-being, and
ability to carry out daily life activities. The disease process can result in damage to the lids with
trichiasis, notching entropion, and ectropion. Corneal damage can result in inflammation,
scarring, loss of surface smoothness, and loss of optical clarity. If severe inflammation develops,
corneal perforation can occur.

Race
No known studies demonstrate racial differences in the incidence of blepharitis. Rosacea may be
more common in fair-skinned individuals, although this finding may be only because it is more
easily and frequently diagnosed in these individuals.

Sex
No well-designed studies of differences in the incidence and clinical features of blepharitis
between the sexes have been found.

Age
Seborrheic blepharitis is more common in an older age group. The apparent mean age is 50
years.

Clinical
History
Patients with blepharitis typically present with symptoms of eye irritation, itching, erythema of
the lids, and/or changes in the eyelashes.

Common complaints include the following:

o Burning
o Watering
o Foreign body sensation
o Crusting and mattering of the lashes and medial canthus
o Red lids
o Red eyes
o Photophobia
o Pain
o Decreased vision

The condition most typically has a chronic course with intermittent exacerbations and
eruptions of symptomatic disease. Seborrheic dermatitis can be associated with symptoms of
scalp itching, flaking, and oily skin. Rosacea can be associated with a red and swollen nose
(rhinophyma), facial flushing, broken and distended vessels in the face, pustules, oily skin, and
eye irritation.

Physical

External examination of patients with blepharitis often demonstrates findings of

associated conditions. Herpetic skin disease can be associated with erythema and vesicle
formation. Seborrheic dermatitis is typified by oily skin and flaking from the scalp or brows.
Rosacea is associated with pustules, rhinophyma, telangiectasias, erythema, and pustules.

Gross examination of the eyelids shows erythema and crusting of the lashes and lid
margins.

Slit lamp examination shows additional features, including loss of lashes (madarosis),
whitening of the lashes (poliosis), scarring and misdirection of lashes (trichiasis), crusting of the
lashes and meibomian orifices, eyelid margin ulcers, plugging and "pouting" of the meibomian
orifices, telangiectasias, and lid irregularity (tylosis).

The conjunctiva usually shows papillary injection.

Corneal findings can include punctate epithelial erosions, marginal infiltrates, marginal
ulcers, pannus, and phlyctenule formation. Corneal involvement occurs most commonly at the

positions where the limbus is crossed by the upper and lower lid margins, at the 2-, 4-, 8-, and
10-o'clock positions. Corneal infiltrates can progress to infection and even perforation.

The anterior variant of blepharitis involves mainly the lashes and associated oil glands.
Various formations of debris adhere to the lashes.
o Crusting refers to flakes of material that adhere to the lashes and usually
represents seborrheic disease. The epithelial material is often referred to as
scurf.
o A collarette is a ringlike formation around the lash shaft that occurs with
staphylococcal disease. Staphylococcal blepharitis is typified by the
formation of collarettes on the lashes.
o A sleeve is a tube of material that also surrounds the lash. Sleeving is
associated with infection by the eyelash parasite, Demodex.
o Ulcers form at the base of the lashes. They are covered by a crust of fibrin,
which is lifted up as the lash shaft grows.
o Seborrheic blepharitis also involves primarily the anterior lid and is
associated with the formation of greasy crusts of material, which are
adherent to the eyelash shaft.

Corneal disease is most common with the staphylococcal variant of anterior lid disease.
Posterior blepharitis mainly is related to dysfunction of the meibomian glands.
Alterations in secretory metabolism and function lead to disease. The meibomian secretions
become more waxlike and begin to block the gland orifices. The stagnant material becomes a
growth medium for bacteria and can seep into the deeper eyelid tissue layers, causing
inflammation. These processes lead to gland plugging, inspissated material, inflamed orifices,
and formation of chalazia.

Various corneal changes can also result from posterior blepharitis.

Causes

Some specific causes of blepharitis may include the following:

o Rosacea
o Herpes simplex dermatitis

o Varicella-zoster dermatitis
o Molluscum contagiosum
o Allergic or contact dermatitis
o Seborrheic dermatitis
o Staphylococcal dermatitis
o Parasitic infections, such as Demodex and Phthiriasis palpebrarum[1,2,3 ]

Chronic blepharitis has been associated with exposure to chemical fumes, smoke, smog,
and other irritants.

Acute blepharitis is most commonly due to allergic drug or chemical reaction.

Sjogren syndrome may present as blepharitis.

Differential Diagnoses
Basal Cell Carcinoma, Eyelid
Cellulitis, Preseptal
Chalazion
Conjunctivitis, Bacterial
Conjunctivitis, Viral
Contact Lens Complications
Dermatitis, Contact
Dry Eye Syndrome

Hordeolum
Keratitis, Bacterial
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Epidemic
Keratoconjunctivitis, Sicca
Keratoconjunctivitis, Superior Limbic
Ocular Rosacea
Trichiasis

Other Problems to Be Considered

Seborrheic dermatitis
Herpetic eye disease
Parasitic infections, such as Demodex or Phthiriasis palpebrarum[1,2,3 ]

Workup
Laboratory Studies

In general, diagnostic tests do not typically need to be performed for suspected

blepharitis. Research and other rare protocols may involve eyelid margin cultures,
transillumination studies of the meibomian glands, marginal biopsies, or even analysis of gland
secretions.

Testing patients with blepharitis for tear insufficiency or nasolacrimal drainage problems
is appropriate because these can be associated with blepharitis and can often complicate
management.

Histologic Findings
Seborrheic dermatitis is characterized histologically by spongiosis, mild perivascular,
lymphohistiocytic, mononuclear cellular infiltrates in the superficial dermis. Staphylococcal
blepharitis is a chronic nongranulomatous inflammation, usually with neutrophils and, often,
acanthosis or parakeratosis.

Treatment
Medical Care
A systematic and long-term commitment to a program of eyelid margin hygiene is the basis of
treatment of blepharitis. Clinicians must ensure that patients recognize that the management of
blepharitis is a process, which must be carried out for prolonged periods of time. This
understanding helps reduce "doctor shopping," a process in which a patient goes from physician
to physician, seeking some panacea for this frustrating condition.[4 ]

Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential
steps.
o First, application of heat to warm the eyelid gland secretions and to promote
evacuation and cleansing of the secretory passages is essential. Patients commonly
are directed to use soaked warm compresses and to apply them to the lids
repeatedly. Warm water in a washcloth, soaked gauze pads, or microwaved, soaked
cloths can be used. Patients should be instructed to use extreme care and to avoid
the use of excessive heat.
o Second, the eyelid margin is washed mechanically to remove adherent material,
such as scurf, collarettes, and crusting, and to clean the gland orifices. This can be
completed with a warm washcloth or with gauze pads. Water often is used,
although some clinicians prefer that a few drops of baby shampoo be mixed in one
bottle cap full of warm water to form a cleaning solution. Attention must be

directed to gentle mechanical jostling or scrubbing of the eyelid margin itself, not
the skin of the lids or of the bulbar conjunctival surface. Vigorous scrubbing is not
necessary and may be harmful.
o Third, an antibiotic ointment is applied to the eyelid margin after it has been
soaked and scrubbed. Commonly used agents include erythromycin or
sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be
used for short courses, although their use is less appropriate for long-term
management.

Specific clinical situations may require additional treatment. Refractory cases of

blepharitis often respond to oral antibiotic use. One- or two-month courses of tetracycline
often are helpful in reducing symptoms in patients with more severe disease. Tetracycline
is believed not only to reduce bacterial colonization but also to alter metabolism and
reduce glandular dysfunction. The use of metronidazole is being studied.

Tear film dysfunctions can prompt use of artificial tear solutions, tear ointments, and
closure of the puncta. Associated conditions, such as herpes simplex, varicella-zoster, or
staphylococcal skin disease, can require specific antimicrobial therapy based on culture.
Seborrheic disease is often improved by the use of shampoos with selenium, although its
use around the eyes is not recommended. Allergic dermatitis can respond to topical
corticosteroid therapy.

Conjunctivitis and keratitis can result as a complication of blepharitis and require

additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can
greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can
be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated
empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens
sent for diagnostic slides and for culture and sensitivity testing.

Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid
positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms.
These conditions often are very refractory to simple management steps. Trichiasis is
treated with epilation, destruction of the follicles via electric current, laser, or
cryotherapy, or with surgical excision. Entropion or ectropion can develop and
complicate the clinical situation and may require referral to an oculoplastics surgeon.

Surgical Care
Surgical care for blepharitis is needed only for complications such as chalazion formation,
trichiasis, ectropion, entropion, or corneal disease.

Consultations
Patients with refractory acne rosacea may benefit from a consultation with a dermatologist.

Diet
Patients with poor nutrition may be at a higher risk for blepharitis.

Medication
Useful medications in the treatment of blepharitis may include topical antibiotics, topical
corticosteroids, and oral antibiotics. Typical blepharitis may be treated with a hygiene regimen
and topical antibiotic ointment. Use of combination corticosteroid and antibiotic ointment should
not be long term but may prove useful in reduction of inflammation in difficult cases. Oral
tetracyclines may be required for refractory cases. Also, a combination antibiotic and steroid
drop may be required for associated corneal disease.[5 ]

Topical antibiotic ointments

Useful in targeting offending pathogens, usually Staphylococcus aureus (and possibly other
Staphylococcus, Propionibacterium, Demodex, and Pityrosporum species, which chronically
infect the lashes); the mechanism of action seems to be reduction of staphylococcal lipase
production more than actual bacterial elimination.
Erythromycin ophthalmic (E-Mycin)
Erythromycin ointment is applied to lid margins with a clean vector, such as a cotton swab or a
clean fingertip, after crusting and debris have been removed with gentle cleansing or scrubbing.
Dosing
Adult

Apply a small amount (0.5-inch ribbon) topically to the outer lid 3-4 times qd
Pediatric

Not established
Interactions
None reported
Contraindications
Documented hypersensitivity to erythromycin or ointment additives
Precautions
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus
Precautions

Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or
repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible
organisms and may lead to a secondary infection (take appropriate measures if superinfection
occurs)

Topical antibiotic/corticosteroid suspension/ointment

Topical corticosteroids, combined with an antibiotic, may be useful in the short-term treatment of
blepharitis to decrease inflammation and more quickly diminish symptoms. Long-term use is not
recommended. An ointment may be used for blepharitis, while a drop may be needed if
associated corneal disease develops.

Sulfacetamide sodium and prednisolone acetate (Blephamide)

Sulfacetamide is an antibiotic that, like erythromycin, has been shown to be effective against
staphylococci. The combined corticosteroid is useful in decreasing inflammation and decreasing
symptoms. Use of the 2 agents combined has been shown to increase patient compliance.
Blephamide is available in an ophthalmic suspension and in an ointment, both containing the
same concentrations of active ingredients (10% sulfacetamide/0.2% prednisolone).
Dosing
Adult

Ointment: 0.5-inch ribbon topically to affected lid(s) 3-4 times qd and once or twice at night;
discontinuation should be gradual
Drops: May be instilled 1 gtt 3-4 times qd; gradual discontinuation is necessary
Pediatric

Not established
Interactions
Decreases effects of silver compounds and gentamicin
Contraindications
Documented hypersensitivity to any ingredients, sulfonamides, or corticosteroids; viral,
mycobacterial, and fungal eye disease; glaucoma or ocular hypertension
Precautions
Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus
Precautions

Use may cause glaucoma and posterior subcapsular cataract formation; rarely, fatalities have
occurred due to severe reactions to sulfonamides, including Stevens-Johnson syndrome, toxic
epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, or other blood

dyscrasias; if inflammation or pain persists longer than 48 h or becomes aggravated, the patient
should discontinue and consult a physician; consult a Physicians' Desk Reference or package
insert for further details

Oral antibiotics
Staphylococcal blepharitis usually responds more quickly to combined use of topical and oral
antibiotics, although a trial of topical antibiotics alone usually is indicated before oral antibiotics
should be considered. Tetracyclines are the DOC.
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and
rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S
ribosomal subunit(s). Metabolized by the liver and the kidneys. Usually not the DOC for most
staphylococcal infections but has been shown to be effective in the treatment of refractory
blepharitis, in which Staphylococcus aureus is the usual pathogen. Tetracyclines should not be
taken with antacids or foods, but rather, they should be taken 1-2 h after meals.
Dosing
Adult

1-2 g PO divided bid to qid, depending on severity, for 1-2 mo

Pediatric

Not established
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or
bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding
and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of
anticoagulants
Contraindications

Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment

Precautions
Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Has been shown to cause yellow-gray-brown discoloration of the teeth if used during tooth
development (last one half of pregnancy up to age 8 y); photosensitivity is common and
avoidance of the sun is essential; may cause an increase in BUN and should be avoided in those
with impaired renal function; has been linked to the development of pseudotumor cerebri;
superinfection may occur; various adverse reactions may occur; refer to the Physicians' Desk
Reference or package insert for more complete information
Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S
ribosomal subunits of susceptible bacteria.
Dosing
Adult

100-200 mg PO qd; some sources recommend using one half of initial dose during second month
Pediatric

Not established
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or
bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants;
tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and
increased risk of pregnancy
Contraindications

Documented hypersensitivity; pregnant or breastfeeding women; renal or hepatic impairment

Precautions
Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce
dose in renal impairment; consider drug serum level determinations in prolonged therapy;
tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause
permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Follow-up
Further Outpatient Care

Patients with blepharitis usually are started on treatment, and they are seen in 2-6 weeks
for a follow-up examination. During this visit, an assessment of the clinical response to therapy
is made. The physician should again emphasize the necessity for a prolonged and dedicated
course of treatment to the patient. Encouragement and support is critical in helping them to
become committed to the course of treatment and to follow it. Additionally, the clinician is able
to keep the focus on rigorous intervention by the patient, rather than accepting blame for not
curing the condition.

Patients are seen based on progress. If little improvement has been made after 1-2 months
of treatment, intervention should be stepped up by prescribing antibiotic-corticosteroid ointments
or oral antibiotics or by treating tear film dysfunction with such measures as punctal closure.
Fluorescein staining is recommended on each examination.

Deterrence/Prevention

Maintenance of a long-term regimen of lid hygiene helps prevent outbreaks of more

symptomatic disease.

Complications

Conjunctivitis and keratitis can result as a complication of blepharitis and require

additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can
greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be
treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but
larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides
and for culture and sensitivity testing.

Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid
positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These
conditions often are very refractory to simple management steps. Trichiasis is treated with
epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical
excision. Entropion or ectropion can develop and complicate the clinical situation.

Prognosis

Overall, the prognosis for patients with blepharitis is good to excellent. Blepharitis only
causes significant morbidity in an extremely small subset of patients. For most, it remains more
of a symptomatic affliction than a true threat to their health and function. Patients experience a
considerable amount of discomfort and misery that can greatly reduce their well-being and
ability to carry out the daily activities of life and work. Recognition of the waxing and waning
course of the disease, and of management through a prolonged program rather than via an instant
cure, helps them to approach the disease in a successful manner.

Patient Education

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also,
see eMedicine's patient education article Eyelid Inflammation (Blepharitis).

Miscellaneous
Medicolegal Pitfalls

Patients with unilateral or very asymmetric blepharitis may have sebaceous cell
carcinoma. An oculoplastics consult may be required for a lid biopsy.

Certain systemic diseases, such as Sjogren syndrome or systemic lupus erythematosus,

may present as blepharitis. Patients should be encouraged to have a complete physical
examination with their primary care physician, and long-term follow-up care is indicated.
References

1. Pinckney J 2nd, Cole P, Vadapalli SP, Rosen T. Phthiriasis palpebrarum: a common

culprit
with
uncommon
presentation. Dermatol
Online
J. Apr
15 2008;14(4):7. [Medline].
2. Divani S, Barpakis K, Kapsalas D. Chronic blepharitis caused by Demodex folliculorum
mites. Cytopathology. Mar 7 2009;[Medline].
3. Dhingra KK, Saroha V, Gupta P, Khurana N. Demodex-associated dermatologic
conditions - A coincidence or an etiological correlate. Review with a report of a rare case
of sebaceous adenoma. Pathol Res Pract. Jan 22 2009;[Medline].
4. Jackson WB. Blepharitis: current strategies for diagnosis and management. Can J
Ophthalmol. Apr 2008;43(2):170-9. [Medline].
5. Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of
posterior blepharitis. Adv Ther. Sep 2008;25(9):858-70. [Medline].
6. Arky R. Acromycin V tetracycline
ed. 1999:1514-1515. [Full Text].

HCl. In:

7. Cohen EJ. Cornea and external disease

Ophthalmol. Jul 2000;118(7):979-81. [Medline].

Physicians'

in

the

Desk

new

Reference. 53rd

millennium. Arch

8. Diaz-Valle D, Benitez del Castillo JM, Fernandez Acenero MJ. Bilateral lid margin ulcers
as the initial manifestation of Crohn disease. Am J Ophthalmol. Aug 2004;138(2):2924. [Medline].
9. Fraunfelder FT, Roy FH, Steinemann TL. Current Ocular Therapy. 5th ed. 2000:72, 374,
378, 450.
10. Held KS. Blepharitis. In: Decision Making in Ophthalmology. 2nd ed. 2000:50-51.
11. Kanski JJ. Marginal blepharitis. In: Clinical Ophthalmology. 1984:1.2-1.4.

12. Roy FH. Ocular Differential Diagnosis. 7th ed. 2002.

13. Sullivan JH. Lids and lacrimal apparatus. In: General Ophthalmology. 14th ed. 1995:7881.
14. Weisbecker CA, Fraunfelder
Ophthalmology. 28th ed. 2000.

FT,

Rhee

D. Physicians'

Desk

Reference

15. Yanoff M, Fine BS. Inflammation. In: Ocular Pathology. 4th ed. 1996:166-168.

for