What is blepharitis?

Blepharitis: Definition, Types, and Management

Blepharitis is a chronic ocular inflammation primarily involving the eyelid margin and is a common cause of chronic ocular irritation that requires targeted treatment based on the specific type and underlying cause. 1

Types and Classification

Blepharitis is classified according to anatomic location:

1. Anterior Blepharitis:

   • Affects eyelid skin, base of eyelashes, and eyelash follicles
   • Subtypes:
     • Staphylococcal: Characterized by scaling, crusting, and erythema of the eyelid margin with collarette formation at the base of the cilia 1, 2
     • Seborrheic: Presents with greasy scaling of the anterior eyelid, often coexisting with seborrheic dermatitis of eyebrows and scalp 2

2. Posterior Blepharitis:

   • Affects the meibomian glands
   • Also known as Meibomian Gland Dysfunction (MGD): Characterized by terminal duct obstruction and/or qualitative/quantitative changes in glandular secretion 1
   • Subtypes: hyposecretory, obstructive, and hypersecretory forms 1

Pathophysiology

• Staphylococcal blepharitis: Staphylococcus aureus is isolated with greater frequency from eyelids of patients with this condition 1
• Bacterial mechanisms: Staphylococcal antigens can directly initiate inflammatory reactions by attaching to bacterial antigen-binding receptors on the corneal epithelium 2
• Meibomian gland dysfunction: Alterations in biochemical composition of meibomian gland secretions can result in tear film instability, promoting increased bacterial growth and leading to evaporative dry eye 2

Clinical Presentation

• Eyelid and ocular irritation and redness 1
• Scaling, crusting, and erythema of the eyelid margin 1
• Collarette formation at the base of eyelashes (pathognomonic for Demodex blepharitis) 3
• Symptoms typically worse in the morning (distinguishing from aqueous deficient dry eye, which worsens later in the day) 1
• Possible complications:
  • Loss of eyelashes
  • Corneal involvement (punctate epithelial erosions, marginal infiltrates)
  • Peripheral corneal epithelial defects
  • Corneal neovascularization 1
  • In children: induced astigmatism, keratopathy, amblyopia, vision loss, or corneal perforation 1

Management Approach

Important: Blepharitis is typically a chronic condition that cannot be permanently cured, and successful management depends on patient compliance with a treatment regimen 1.

First-line Treatment:

1. Eyelid Hygiene:

   • Regular cleaning of eyelid margins
   • Warm compresses to loosen crusts and secretions
   • Careful removal of scales and crusts before applying medication 4

2. Topical Antibiotics:

   • Bacitracin ophthalmic ointment applied directly into the conjunctival sac 1-3 times daily 5
   • For blepharitis, ointment should be spread uniformly over lid margins after careful removal of scales and crusts 5

3. Combination Therapy:

   • Topical antibiotic ointments with or without corticosteroids for inflammatory components 1
   • Fixed combinations of topical antibiotic and corticosteroid can effectively address both infectious and inflammatory components 6

For Specific Types:

• Posterior Blepharitis/MGD: In-office heat therapy/thermal pulsation treatment to clear meibomian gland obstruction 4
• Demodex Blepharitis: Recent trials suggest lotilaner ophthalmic solution 0.25% may eradicate Demodex mites and eliminate collarettes 3

For Severe or Refractory Cases:

• Oral Antibiotics: May be appropriate in some patients 7
• Caution: Oral azithromycin may produce cardiac arrhythmias in patients with cardiovascular problems 1

Important Clinical Considerations

• If blepharitis does not respond to therapy, consider:

  • Carcinoma
  • Immune-mediated diseases
  • Particularly if associated with loss of eyelashes and/or conjunctival cicatricial changes 1, 2

• Early diagnosis and appropriate treatment can:

  • Prevent vision loss
  • Prevent disfigurement
  • Be potentially lifesaving in cases of underlying serious conditions 1

• The multifactorial nature of blepharitis often requires long-term management of underlying causes rather than seeking a treatment panacea 8