What is the likely diagnosis and appropriate initial treatment for a patient presenting with itchy eyes and eyelids, tearing, burning sensation, eye fatigue, blurred vision, reduced eye movement, and eyelid swelling?

Likely Diagnosis: Blepharitis with Meibomian Gland Dysfunction

The constellation of itchy eyes and eyelids, watery discharge, burning sensation, eye fatigue, blurred vision, and eyelid swelling most strongly suggests blepharitis, particularly with meibomian gland dysfunction (MGD), which is a chronic inflammatory condition of the eyelid margins. 1

Key Diagnostic Features Supporting Blepharitis

The symptom pattern you describe aligns precisely with blepharitis:

• Itching, burning, and irritation are cardinal symptoms of chronic blepharitis 1, 2
• Tearing (watery eyes) occurs as a compensatory response to tear film instability caused by MGD 1
• Eye fatigue and blurred/fluctuating vision result from tear film dysfunction and are characteristic of posterior blepharitis/MGD 1
• Eyelid swelling represents the inflammatory component of chronic eyelid margin disease 1
• Morning symptom predominance would be typical of blepharitis (versus dry eye, which worsens later in the day) 1

Critical Differential Diagnosis Considerations

When to Suspect Allergic Conjunctivitis Instead

Allergic conjunctivitis would present with:

• Bilateral itching as the dominant symptom with conjunctival injection but no ciliary flush 3
• Absence of pain and photophobia with normal visual acuity 3
• Seasonal or exposure-related pattern 4

However, the presence of burning sensation, eye fatigue, and blurred vision points more toward blepharitis than pure allergic disease 1, 2.

Red Flags Requiring Urgent Ophthalmology Referral

You must immediately refer to ophthalmology if any of these are present: 5

• Moderate-to-severe pain with photophobia (suggests keratitis or uveitis)
• Significant visual loss beyond mild blurring
• Corneal opacity or infiltrate on examination
• Unilateral presentation with vesicular rash (herpes simplex keratitis)

The "decreased extraocular movements" you mention is concerning and requires urgent ophthalmology evaluation to exclude orbital involvement, thyroid eye disease, or other serious pathology 6.

Initial Management Approach

First-Line Treatment (Patient Can Start Immediately)

Eyelid hygiene is the cornerstone of blepharitis management and must be performed daily long-term: 1

1. Warm compresses for 5-10 minutes twice daily to soften meibomian gland secretions 1
2. Eyelid massage after warm compresses to express meibomian glands (especially important for posterior blepharitis/MGD) 1
3. Eyelid cleansing with diluted baby shampoo or commercial eyelid scrub to remove debris and scales 1

Additional Treatment Options

Topical antibiotic ointment (such as erythromycin or bacitracin) applied to eyelid margins can be effective, particularly if staphylococcal blepharitis is suspected 1

Artificial tears (preservative-free) can provide symptomatic relief for associated tear film instability 1

Oral antibiotics (doxycycline 50-100mg daily or azithromycin) may be considered for moderate-to-severe MGD, though azithromycin carries cardiac risk warnings 1

Critical Patient Education Points

Patients must understand that blepharitis is typically a chronic condition that cannot be permanently cured 1. Success depends entirely on:

• Daily compliance with eyelid hygiene regimen 1
• Expectation of periods of exacerbation and remission 1
• Long-term commitment to management (symptoms often present for 6.5-11.6 years) 1

Important Clinical Pitfalls to Avoid

Never start topical corticosteroids without proper slit-lamp examination, as they can worsen infectious keratitis from herpes simplex, fungus, or other pathogens 5

Do not dismiss persistent unilateral blepharitis with eyelash loss or conjunctival scarring—this may represent sebaceous gland carcinoma or immune-mediated disease requiring biopsy 1

The "decreased extraocular movements" mentioned requires immediate evaluation to exclude orbital cellulitis, thyroid eye disease, or other serious orbital pathology 6

When to Escalate Care

Refer to ophthalmology if: 1

• No improvement after 2-4 weeks of appropriate eyelid hygiene
• Progressive vision loss beyond mild fluctuation
• Corneal involvement suspected (pain, photophobia, decreased vision)
• Recurrent hordeola or chalazia despite treatment
• Concern for malignancy (unilateral, eyelash loss, scarring)