Aetiology

Blepharitis is a chronic inflammation of the eyelids that primarily affects the eyelid margins and is one of the most common presentations in primary eye care. Blepharitis is conventionally classified as:

Anterior blepharitis (also known as Anterior Lid Margin Disease)

• bacterial (usually staphylococcal)
  • caused by (1) direct infection, (2) reaction to staphylococcal exotoxin or (3) allergic response to staphylococcal antigen
• seborrhoeic (disorder of the ciliary sebaceous glands of Zeis).

Posterior blepharitis (also known as Posterior Lid Margin Disease)

• meibomian gland dysfunction (MGD)
  • bacterial lipases break down meibomian lipids
  • meibomian secretion becomes abnormal both chemically and physically
  • tear film becomes unstable.

Mixed anterior and posterior blepharitis

• elements of both conditions are present.

All of these conditions are typically bilateral, and chronic or relapsing.

Dry Eye Disease is present in:

• 50% of people with staphylococcal blepharitis
• 25-40% of people with seborrhoeic blepharitis.

Posterior blepharitis is a leading cause of evaporative dry eye.

A significant association has been found between Demodex infestation and blepharitis (see evidence base), though the role of the mite in the pathogenesis of the condition is unclear.

Predisposing factors

Seborrhoeic dermatitis (for example, of the scalp).
Ocular rosacea (a cause of posterior blepharitis).

Demidicosis

• Demodex folliculorum is an ectoparasite that occurs normally in the
  lash follicles
• Demodex brevis, also an ectoparasite, is found in meibomian glands.

Long-term contact lens wear.

Symptoms of blepharitis (lid margin disease)

Blepharitis may be asymptomatic. However, when present, the symptoms of anterior blepharitis, posterior blepharitis and mixed anterior and posterior blepharitis are similar:

• ocular discomfort, soreness, burning, itching
• mild photophobia
• symptoms of dry eye including blurred vision and contact lens intolerance.

Signs of blepharitis (lid margin disease)

Anterior blepharitis (staphylococcal)

• lid margin hyperaemia
• lid margin swelling
• crusting of anterior lid margin (scales at bases of lashes)
• misdirection of lashes
• loss of lashes (madarosis)
• recurrent styes and (rarely) chalazia
• conjunctival hyperaemia
• secondary signs include: punctate epithelial erosion over lower third of cornea; marginal keratitis; phlyctenulosis; neovascularisation and pannus; mild papillary conjunctivitis.

Anterior blepharitis (seborrhoeic)

• lid margin hyperaemia
• oily or greasy deposits on lid margins
• conjunctival hyperaemia.

Anterior blepharitis (Demodex)

• lid margin hyperaemia
• 'cylindrical dandruff’: characteristic clear sleeve (collarette) covers base of lash, extending further up lash than flat staphylococcal rosettes
• persistent infestation of the lash follicles may lead to misalignment, trichiasis or madarosis.

Posterior blepharitis (MGD is the most common cause)

• thick and/or opaque secretion at meibomian gland orifices, making it difficult or impossible to express oil by finger pressure
• foam in the lower tear film meniscus (due to excess tear film lipid)
• plugging of duct orifices with abnormal lipid leading to dilatation of glands and formation of microliths and chalazia
• conjunctival hyperaemia
• evaporative tear deficiency, unstable pre-corneal tear film
• secondary signs include: punctate epithelial erosion over lower third of cornea; marginal keratitis; scarring; neovascularisation and pannus; mild papillary conjunctivitis.

Differential diagnosis

Allergy.
Dermatoconjunctivitis medicamentosa (see Clinical Management Guideline on Conjunctivitis Medicamentosa).
Eyelid dermatitis.
Dacryocystitis.
Parasitic infestation (e.g. Phthirus pubis infestation of lid margins).
Preseptal cellulitis.
Herpes (simplex or zoster).
Meibomian gland carcinoma (usually unilateral).

Management by optometrist

Practitioners should work within their scope of practice and where necessary seek further advice or refer the patient elsewhere.

GRADE* level of evidence and strength of recommendation always relates to the statement(s) immediately above.

Management of Dry Eye Disease, if also present: see Clinical Management Guideline on Dry Eye Disease.

Patients should be made aware of the importance of the chronic nature of the condition and the need of on-going treatment.

Lid hygiene, consisting of lid cleansing using a variety of measures, is the first line of management regardless of type of blepharitis.

Lid cleansing measures wipe away bacteria and deposits from lid margins and lead to improved signs and symptoms in the majority of individuals. However, there is insufficient high quality evidence on the comparative efficacy of the various lid hygiene regimes. There is evidence that long-term compliance with lid hygiene measures may be poor.
(GRADE*: Level of evidence = moderate, Strength of recommendation = strong)

Wet warm compresses loosen collarettes and crusts in anterior blepharitis. Dry warm compresses melt meibum in posterior blepharitis (compress applied to lid skin twice daily for not less than 5 minutes at 40°C. Commercial products and electronic heating devices are available that are able to maintain temperatures in this region).
(GRADE*: Level of evidence = weak, Strength of recommendation = strong)

Intense Pulsed Light (IPL) therapy has been recommended for the management of meibomian gland dysfunction (MGD). However, a 2020 Cochrane Review found a lack of evidence as to the effectiveness and safety of this treatment modality.
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Advise the avoidance of cosmetics, especially eye liner and mascara. Advise patient to return/seek further help if symptoms persist.

Complete eradication of the blepharitis may not be possible, but long-term compliance with these measures should reduce symptoms and minimise the number and severity of relapses.

Staphylococcal and seborrhoeic blepharitis may benefit from topical antibiotics if not controlled by first line management

• antibiotic ointment (e.g. chloramphenicol) twice daily; place in eyes or rub into lid margin with fingertip
• short course of topical azithromycin (NB off-label use).

(GRADE*: Level of evidence = moderate, Strength of recommendation = weak)

In patients with posterior blepharitis, systemic antibiotics may be effective as a second line treatment

• consider prescribing a systemic tetracycline, such as doxycycline or minocycline (contraindicated in pregnancy, lactation and in children under 12 years; various adverse effects have been reported). Such treatment will need to be continued for several weeks or months and the dosage may need to be varied from time to time
• where tetracyclines are contraindicated, consider prescribing oral
  erythromycin or azithromycin
• a 2021 Cochrane review reported that there is insufficient evidence on the use of oral antibiotics for chronic blepharitis. Low certainty evidence found that oral antibiotics could improve clinical signs compared to placebo, but may cause more adverse events.

(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Consider Demodex blepharitis if characteristic ‘cylindrical dandruff’ is present at roots of eyelashes or if blepharitis is refractory to treatment. Although Demodex blepharitis is commonly treated with tea tree oil (TTO), there is uncertainly regarding its effectiveness. However, if used, lower concentrations are recommended to avoid ocular toxicity. Preparations containing 4-terpineol (the proposed active ingredient of TTO) are commercially available for patient use.
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Management category

B2: alleviation/palliation: normally no referral.

In patients who do not respond to therapy the possibility of carcinoma or
immune mediated diseases should be considered, particularly if the blepharitis is associated with loss of eyelashes and/or cicatricial changes.

A3: in unilateral cases, if meibomian gland carcinoma is suspected, refer urgently (within one week) to ophthalmologist.

Possible management in secondary care or local primary/community pathways where available

Microbiological investigations including culture and sensitivity testing. To minimise risk of post-operative infection, management of blepharitis prior to ocular surgery (e.g. trabeculectomy).

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)

Sources of evidence

Amescua G, Akpek EK, Farid M, Garcia-Ferrer FJ, Lin A, Rhee MK, Varu DM, Musch DC, Dunn SP, Mah FS; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Blepharitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P56-P93

Bilkhu PS, Naroo SA, Wolffsohn JS. Randomised masked clinical trial of the MGDRx EyeBag for the treatment of meibomian gland dysfunction-related evaporative dry eye. Br J Ophthalmol. 2014;98(12):1707-11

Cote S, Zhang AC, Ahmadzai V, Maleken A, Li C, Oppedisano J, Nair K, Busija L, Downie LE. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev 2020: 3: CD013559

Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O’Brien T, Rolando M, Tsubota K, Nichols KK. The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050-2064

Jones L, Downie LE, Korb D, Benitez-Del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu Y, Seo KY, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628

Kashkouli MB, Fazel AJ, Kiavash V, Nojomi M, Ghiasian L. Oral azithromycin versus doxycycline in meibomian gland dysfunction: a
randomised double-masked open-label clinical trial. Br J Ophthalmol. 2015;99(2):199-204

Lindsley K, Matsumura S, Hatef E, Akpek EK. Interventions for chronic blepharitis. Cochrane Database Syst Rev 2012, 5: CD005556

Navel V, Mulliez A, Benoist d'Azy C, Baker JS, Malecaze J, Chiambaretta F, Dutheil F. Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis. Ocul Surf. 2019; 17(4):655-669

Onghanseng N, Ng SM, Halim MS, Nguyen QD Oral antibiotics for chronic blepharitis. Cochrane Database Syst Rev. 2021;6(6):CD013697

Pflugfelder SC, Karpecki PM, Perez VL. Treatment of blepharitis: recent clinical trials. Ocul Surf. 2014;12(4):273-84

Sabeti S, Kheirkhah A, Yin J, Dana R. Management of meibomian gland dysfunction: a review. Surv Ophthalmol. 2020;65(2):205-207

Savla K, Le JT, Pucker AD Tea tree oil for Demodex blepharitis. Cochrane Database Syst Rev 2020;6(6):CD013333

Sung J, Wang MTM, Lee SH, Cheung IMY, Ismail S, Sherwin T, Craig JP. Randomized double-masked trial of eyelid cleansing treatments for blepharitis. Ocul Surf. 2018;16(1):77-83

Zhang AC, Muntz A, Wang MTM, Craig JP, Downie LE. Ocular Demodex: a systematic review of the clinical literature. Ophthalmic Physiol Opt. 2020;40(4):389-432

Zhao YE, Wu LP, Hu L, Xu JR. Association of blepharitis with Demodex: A meta-analysis. Ophthalmic Epidemiology 2012;19(2),95-102

Blepharitis (Lid Margin Disease)
Version 17
Date of search 15.12.21 
Date of revision 24.03.22
Date of publication 06.07.22
Date for review 14.12.23
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