Blepharitis (Lid Margin Disease)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Blepharitis (Lid Margin Disease)

 

 

 

 

 

 

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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

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

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)
Dacryocystitis
Parasitic infestation (e.g. Phthirus pubis infestation)
Preseptal cellulitis
Herpes (simplex or zoster)
Meibomian gland carcinoma (usually unilateral)

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

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

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

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)

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 longterm
compliance with lid hygiene measures may be poor.
(GRADE*: Level of evidence = moderate, Strength of recommendation = strong)

Intense Pulsed Light (IPL) therapy has been recommended for the management of meibomian gland dysfunction (MGD). However, a recent
Cochrane Review found a lack of evidence as to the effectiveness and safety of this treatment modality

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

Pharmacological

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
  • topical azithromycin (NB off-licence 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

(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. Demodex mites can be dose-dependently killed by weekly lid cleansing with 50% tea tree oil (see evidence base), but this should be undertaken only by experienced practitioners as such preparations are toxic to the ocular surface. Preparations containing 4-terpineol (an active ingredient of tea tree oil) 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)

Possible management by ophthalmologist

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

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see https://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 of Systematic Reviews 2020, Issue 3. Art. No.: 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. Inv 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 of Systematic Reviews 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

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. 2019 Sep 5. pii: S0039-6257(19)30253-X. doi: 10.1016/j.survophthal.2019.08.007. [Epub ahead of print]

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

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

Plain language summary

Blepharitis is a condition in which chronic (i.e. long-term) inflammation of the eyelid margins causes symptoms of eye irritation. Sometimes there are no symptoms. There are two types of blepharitis, which sometimes occur together:

  • Anterior blepharitis, which affects the outside front edge of the eyelids (near or among the roots of the eyelashes)
  • Posterior blepharitis, which is also called Meibomian Gland Dysfunction (MGD), results when the condition affects the inside rims of the eyelids (just behind the eyelashes) which contain the meibomian glands. (The meibomian glands produce a thin layer of oil which normally prevents the tears from evaporating too quickly; if they are inflamed, this mechanism does not work properly)

Lid hygiene reduces symptoms for the majority of patients with either anterior or posterior blepharitis. Antibiotics in the form of eye drops or ointments (and in some cases antibiotics taken by mouth) can potentially lessen symptoms and are effective in clearing bacteria from the eyelid margins. However, there is no strong evidence that any of these treatments can completely cure the condition.

Blepharitis (Lid Margin Disease)
Version 16
Date of search 17.11.19 
Date of revision 28.01.21
Date of publication 23.07.21
Date for review 16.11.21
© College of Optometrists

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