Clinical Diagnosis of Blepharitis
The diagnosis of blepharitis is primarily based on a characteristic patient history and specific slit-lamp biomicroscopic findings, with no single definitive clinical diagnostic test available. 1
Key Diagnostic Elements
Patient History
- Symptoms including redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, blurring or fluctuating vision, contact lens intolerance, photophobia, increased frequency of blinking, and recurrent hordeolum 1
- Time of day when symptoms occur (morning symptoms typical of blepharitis, evening symptoms more typical of aqueous deficient dry eye) 1
- Duration of symptoms and unilateral versus bilateral presentation 1
- Exacerbating factors such as smoke, allergens, wind, contact lenses, low humidity, retinoids, diet, alcohol consumption, and eye makeup 1
- Associated systemic conditions including rosacea, atopy, psoriasis, and graft-versus-host disease 1
- Medication history, particularly isotretinoin and dupilumab which are associated with blepharitis 1, 2
External Examination
Skin Assessment
- Evaluate for changes consistent with rosacea such as rhinophyma, erythema, telangiectasia, papules, pustules, and hypertrophic sebaceous glands in malar areas 1
Eyelid Examination
- Abnormal eyelid position (ectropion/entropion), incomplete eyelid closure (lagophthalmos), blink response, and eyelid laxity 1
- Loss, breakage, or misdirection of eyelashes 1
- Vascularization or hyperemia of eyelid margins 1
- Abnormal deposits/sleeves at the base of eyelashes (cylindrical dandruff is pathognomonic for Demodex infestation) 1, 2
- Ulceration, vesicles, scaling, hyperkeratosis 1
- Chalazion/hordeolum 1
- Scarring 1
Slit-Lamp Biomicroscopy
Tear Film Evaluation
- Tear meniscus height 1
- Tear film break-up time and pattern 1
- Foamy discharge on the eyelid margin 1
- Debris in the tear film 1
Posterior Eyelid Margin Assessment
- Abnormalities of meibomian orifices (capping, pouting, retroplacement, metaplasia, obliteration) 1
- Character of meibomian secretions (expressibility, thickness, turbidity, color) 1
- Vascularization, keratinization, nodularity 1
- Thickening and scarring/fibrosis 1
Tarsal Conjunctiva (with lid eversion)
- Appearance of meibomian glands and ducts (dilation and inflammation) 1
Bulbar Conjunctiva
- Hyperemia 1
- Phlyctenules, follicles 1
- Conjunctival chalasis 1
- Punctate staining with fluorescein, rose bengal, or lissamine green 1
Cornea
- Epithelial defects, punctate staining 1
- Edema, infiltrates, ulcers, and/or scars 1
- Vascularization, scarring, including pannus 1
- Phlyctenules 1
Specialized Diagnostic Tests
- Microbiologic cultures of eyelid margins for patients with recurrent anterior blepharitis with severe inflammation or those not responding to therapy 1
- Microscopic evaluation of epilated eyelashes for Demodex mites (place eyelashes on glass slide with fluorescein drop and cover slip) 1
- Assessment of meibomian gland expression by applying pressure to lower eyelids with fingers or cotton-tipped applicator 1
- Interferometry technology to analyze lipid layer thickness, blink dynamics, and meibomian gland structure 1
Differential Diagnosis Considerations
- Consider carcinoma in cases of chronic blepharitis unresponsive to therapy, especially with unilateral involvement 1
- Eyelid biopsy may be indicated for marked asymmetry, resistance to therapy, or unifocal recurrent chalazia 1
- Signs of concern include loss of normal eyelid margin anatomy, focal lash loss (ciliary madarosis) 1
- Evaluate for conjunctival cicatricial changes that might suggest ocular mucous membrane pemphigoid 1
Treatment Approaches
- Warm compresses and eyelid hygiene/cleansing form the mainstay of treatment 1, 3
- Eyelid massage for meibomian gland dysfunction to express the glands 1
- Topical antibiotics to reduce bacterial load 1, 4
- Topical corticosteroids for marked inflammation 1, 4
- Systemic antibiotics may be appropriate in some patients 4
- Omega-3 supplements may provide benefit 5
Clinical Pitfalls and Caveats
- Blepharitis is a chronic condition with periods of exacerbation and remission; patients must understand that a cure is usually not possible 1, 6
- Pediatric blepharokeratoconjunctivitis is often unrecognized and can be more severe, potentially leading to amblyopia 1
- Asymmetric presentation in children is often confused with herpetic disease 1
- Carcinoma can masquerade as blepharitis, particularly with unilateral involvement 1
- Medications like isotretinoin and dupilumab can induce or worsen blepharitis 1, 2
- Blepharitis is a risk factor for endophthalmitis after intraocular surgery; consider addressing moderate to severe blepharitis prior to intraocular procedures 1