Blepharitis
Exam Tips
- In OSCEs, distinguish anterior (collarettes/scales at lashes) from posterior disease (meibomian plugging and thick secretions), then add dry-eye links.
- Red flags needing urgent same-day ophthalmology: reduced vision, severe unilateral pain/redness, painful or restricted eye movements, diplopia/proptosis, fever, or corneal signs.
- Persistent unilateral 'blepharitis' with lash loss, lid distortion, ulceration, bleeding, or recurrent chalazion should trigger concern for sebaceous gland carcinoma.
- Routine swabs are not required for typical blepharitis; diagnosis is clinical.
- First-line treatment is not antibiotics but sustained lid hygiene plus warm compresses and massage.
Definition
Blepharitis is a chronic inflammatory disorder of the eyelid margins, usually affecting both eyes and commonly recurring over months to years. It is classified into anterior disease (lash line/skin side), posterior disease (meibomian gland dysfunction), or a mixed pattern, and is frequently linked to ocular surface dryness.
Pathophysiology
Anterior blepharitis is commonly driven by staphylococcal overgrowth and/or seborrhoeic dysfunction at the lash margin, with inflammation thought to involve bacterial products and host hypersensitivity responses. Posterior blepharitis is mainly due to meibomian gland dysfunction: terminal duct obstruction and altered meibum quality reduce the lipid layer of the tear film, increasing evaporation and tear instability. Tear film breakup then perpetuates ocular surface inflammation, producing a chronic cycle of irritation, lid margin inflammation, and dry-eye symptoms.
Risk Factors
- Meibomian gland dysfunction
- Dry eye disease (especially evaporative dry eye)
- Seborrhoeic dermatitis
- Rosacea
- Atopic eczema or psoriasis
- Demodex overpopulation (more common with age)
- Middle age (can occur in children)
- Female sex association in staphylococcal blepharitis
- Contact lens wear and eye makeup (symptom exacerbators)
- Drugs that worsen dry eye: anticholinergics, antihistamines, diuretics, tricyclic antidepressants, antipsychotics
- Oral isotretinoin use
Clinical Features
Symptoms
- Bilateral eyelid soreness, burning or itching
- Crusting/stickiness of lids, typically worse on waking
- Grittiness, foreign-body sensation, fluctuating discomfort
- Intermittent blurred vision that improves with blinking
- Dry-eye symptoms and contact-lens intolerance
- Relapsing-remitting course
Signs
- Lid margin erythema and mild oedema
- Anterior lash debris: hard collarettes/scales (staphylococcal) or greasy deposits (seborrhoeic)
- Posterior lid disease: capped orifices, thick/opaque meibomian secretions, foamy tear meniscus
- Lid margin telangiectasia (anterior and posterior forms)
- Madarosis, trichiasis or poliosis in chronic disease
- Associated conjunctival injection and tear film instability
- Features of associated rosacea/seborrhoeic dermatitis
Investigations
Management
Lifestyle Modifications
- Explain chronic relapsing nature and need for long-term maintenance
- Warm compresses to closed lids for 5-10 minutes, 1-2 times daily during flare
- Lid massage (towards lash line) after heat to express meibomian secretions
- Lid margin cleansing (commercial lid wipes or dilute bicarbonate solution) once or twice daily
- Temporarily stop eye makeup and reduce contact lens wear during active inflammation
- Manage skin comorbidities (rosacea/seborrhoeic dermatitis) and optimize dry-eye care; see Figure from ophthalmology slit-lamp atlas on anterior vs posterior blepharitis
Pharmacological Treatment
Lubricants (ocular surface support)
- Hypromellose 0.3% eye drops: 1 drop 3-4 times daily PRN
- Carbomer 0.2% gel: 1 drop up to 4 times daily
- Paraffin-based lubricating ointment at night PRN
Useful where evaporative dry eye coexists; blurred vision can occur after gels/ointments so warn about driving immediately after use.
Topical antibiotic for anterior staphylococcal blepharitis (if poor response to hygiene, usually specialist/GP-guided)
- Chloramphenicol 1% eye ointment: apply a small amount to lid margins 1-2 times daily for 2-6 weeks (off-label regimen for blepharitis)
- Fusidic acid 1% viscous eye drops: 1 drop twice daily for 1-2 weeks (alternative, off-label depending local practice)
Avoid contact lenses during treatment. Review if no improvement. Chloramphenicol can very rarely cause serious blood dyscrasia; stop and seek urgent advice if fever, sore throat, bruising, or pallor develop.
Oral tetracycline-class therapy for posterior blepharitis/meibomian dysfunction refractory to local care
- Doxycycline 100 mg once daily for 6-12 weeks, then consider dose reduction (for example 50 mg once daily) if prolonged course needed
- Lymecycline 408 mg once daily for 6-12 weeks (alternative)
Counsel on photosensitivity and pill oesophagitis (take with water, remain upright). Contraindicated in pregnancy and generally avoided in breastfeeding and in children under 12 years.
Specialist anti-inflammatory rescue (ophthalmology)
- Short course topical steroid-antibiotic combination, e. g. dexamethasone + chloramphenicol, with taper
Use only with specialist supervision because of risks of steroid-induced glaucoma, cataract, and worsening herpetic keratitis.
Surgical / Interventional
- Incision and curettage for persistent chalazion
- Procedures for lid malposition (entropion/ectropion) when scarring causes mechanical symptoms
- Epilation or definitive lash procedures for troublesome trichiasis
- Biopsy/excision of suspicious unilateral atypical lesions to exclude sebaceous gland carcinoma or other eyelid malignancy
Complications
- Chalazion (meibomian cyst), including recurrent lesions
- External hordeolum (stye)
- Madarosis, trichiasis, or poliosis
- Lid scarring with entropion or ectropion
- Chronic conjunctivitis
- Dry eye disease (keratoconjunctivitis sicca)
- Contact lens intolerance
- Keratitis, corneal neovascularization or scarring with potential visual loss
- Rare corneal ulceration/perforation (higher risk in children)
Prognosis
Blepharitis is usually long term with exacerbations and remissions rather than a one-off curable episode. Most patients improve with consistent eyelid hygiene and adjunct therapy, while serious visual complications are uncommon if red flags and corneal involvement are identified early.