What are the symptoms and treatment options for blepharitis?

Symptoms and Treatment of Blepharitis

Blepharitis presents with symptoms including redness, irritation, burning, tearing, itching, crusting of eyelashes, eyelid sticking, blurring vision, and photophobia, and is best managed with daily warm compresses and eyelid cleansing as first-line treatment. 1

Common Symptoms of Blepharitis

Blepharitis is a chronic inflammatory condition of the eyelids that typically presents with the following symptoms:

Primary Symptoms

• Redness and irritation of eyelid margins
• Burning sensation
• Tearing
• Itching
• Crusting of eyelashes, especially noticeable upon waking
• Loss or breakage of eyelashes in severe cases
• Eyelid sticking, particularly in the morning
• Blurring or fluctuating vision
• Contact lens intolerance
• Photophobia (light sensitivity)
• Increased frequency of blinking
• Recurrent hordeolum (stye) 1

Timing of Symptoms

• Symptoms typically worsen in the morning for blepharitis
• In contrast, aqueous deficient dry eye symptoms typically worsen later in the day 1

Diagnostic Features

Blepharitis is diagnosed primarily through clinical examination, revealing:

• Vascularization or hyperemia of eyelid margins
• Abnormal deposits/crusts at the base of eyelashes
• Eyelid margin telangiectasia
• Meibomian gland orifice narrowing and pouting
• Scaling or hyperkeratosis of the eyelid margin
• Loss, breakage, or misdirection of eyelashes in severe cases 1

Treatment Algorithm

First-Line Treatment

1. Warm compresses:

   • Apply to eyelids for 10-15 minutes
   • Use 3-4 times daily
   • Helps soften crusts and warm meibomian secretions
   • Can use hot tap water on clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave
   • Important: avoid temperatures hot enough to burn skin 1

2. Eyelid cleansing:

   • Perform after warm compress application
   • Options include:
     • Diluted baby shampoo on cotton ball/pad/swab
     • Commercial eyelid cleaners (including those with hypochlorous acid 0.01%)
     • Gentle rubbing at base of eyelashes to remove crusting 1, 2

3. Eyelid massage:

   • Perform gentle massage after warm compress
   • For anterior blepharitis: rub eyelid margins side to side to remove crusting
   • For posterior blepharitis/MGD: vertical massage to express meibomian secretions
   • Caution: avoid aggressive pressure in patients with glaucoma 1, 2

Second-Line Treatment

For cases not responding to first-line treatment:

1. Topical antibiotics:

   • Bacitracin or erythromycin ointment applied to eyelid margins
   • Use 1+ times daily or at bedtime for a few weeks
   • Can be used intermittently to prevent resistance 1

2. Topical perfluorohexyloctane:

   • FDA approved in 2023
   • Prevents tear evaporation
   • Improves symptoms and corneal staining in dry eye disease 1

3. Selenium sulfide:

   • Shows promise for MGD by potentially unblocking meibomian gland orifices
   • Decreases meibum viscosity 1

For Severe or Refractory Cases

1. Oral antibiotics:

   • Doxycycline, minocycline, tetracycline
   • Erythromycin for children and pregnant women 2

2. Topical anti-inflammatory agents:

   • Corticosteroids
   • Cyclosporine 1

Special Considerations

Potential Complications

• Severe staphylococcal blepharitis may lead to:

  • Eyelash loss
  • Eyelid scarring with trichiasis
  • Corneal scarring and neovascularization 1

• Severe ocular rosacea with blepharitis may cause:

  • Superficial punctate keratopathy
  • Corneal neovascularization and scarring
  • Rarely, ulceration and perforation (higher risk in children) 1

Contact Lens Wearers

• Discontinue contact lens wear until condition resolves
• Consider replacing contact lenses and case after resolution
• Daily disposable lenses may help prevent recurrence 2

Maintenance Therapy

• Patients should be advised that blepharitis is often chronic with periods of exacerbation and remission
• Long-term maintenance with warm compresses and eyelid hygiene is typically necessary
• Symptoms often recur when treatment is discontinued 1

Exacerbating Factors to Avoid

• Smoke
• Allergens
• Wind
• Low humidity environments
• Retinoids
• Certain dietary factors and alcohol
• Eye makeup 1

By following this treatment algorithm and addressing exacerbating factors, most patients with blepharitis can achieve significant symptom relief, though complete cure is often not possible in this chronic condition 3.