Definition
A.Blepharitis is dryness and flaking of the eyelashes, resulting from an inflammatory response of the eyelid. It is considered a chronic condition exhibiting intermittent exacerbations of worsening redness and irritation of the eyelid.
Incidence
A.The exact incidence is unknown; however, blepharitis is commonly seen.
Pathogenesis
A.Seborrheic: Excessive shedding of skin cells and blockage of glands.
B.Staphylococcus: Most common bacteria found, responsible for bacterial infection of lid margin.
C.Commonly seen with altered lipid protection and increased bacterial colonization of the ocular surface and eyelids.
D.Allergic dermatitis (contact dermatitis), eczema, psoriasis.
Predisposing Factors
A.Diabetes.
B.Candida.
C.Seborrheic dermatitis.
D.Acne rosacea.
E.Eczema.
F.Aging.
Common Complaints
A.Burning and itching.
B.Lacrimal tearing.
C.Photophobia.
D.Recurrent eye infections, styes, or chalazions.
E.Dry, flaky secretions on lid margins and eyelashes.
F.Gritty sensation to both eyes.
G.Dry eyes.
Other Signs and Symptoms
A.Seborrheic blepharitis: Lid margin swelling and erythema, flaking, nasolabial erythema, and scaling.
B.Staphylococcus aureus blepharitis: Erythema/edema, scaling, burning, tearing, itching, and recurrent stye or chalazia.
C.May have dandruff of scalp and eyebrows.
Subjective Data
A.Elicit onset and duration of signs and symptoms.
B.Note sensations of itching, burning, or pain in the eye.
C.Ask: What makes signs and symptoms worse? What makes signs and symptoms better?
D.Any change in soaps, creams, lotions, or shampoos?
E.Has the patient had similar signs and symptoms in the past?
F.Note any visual change or pain since the last eye exam.
G.Note contributing factors involved, if present. These should include smoking, allergen exposure, contact lenses, and use of retinoid products.
H.Ask about risk for foreign bodies or contact with toxins transferred from hands to eyelids (occupational exposures).
Physical Examination
A.Inspect:
1.Inspect eyes, noting extraocular eye movements (EOMs) of eyes.
2.Examine sclera, pupil, iris, and fundus.
3.Examine eyes for red reflex and corneal light reflex.
4.Note erythema or edema on lid margin; note dryness, scaling, and flakes.
5.Examine for foreign body or corneal abrasion.
6.Assess vision using Snellen chart.
Diagnostic Tests
A.None.
Differential Diagnoses
A.Blepharitis:
1.S. aureus.
2.Seborrheic.
3.Demodex folliculorum.
B.Conjunctivitis.
C.Squamous cell carcinoma.
D.Stye (hordeolum).
E.Chalazion.
F.Upper respiratory infection.
G.Sinusitis with periorbital involvement.
Plan
A.General interventions:
1.Assess patient and rule out bacterial infection and vision changes.
2.Patients with frequent recurrent blepharitis need further follow-up with an ophthalmologist.
B.Patient teaching:
1.Wash eye with antibacterial soap and water. Should use over-the-counter (OTC) eyelid scrub product or baby shampoo.
2.Apply warm compresses to eye for comfort daily for approximately 10 to 20 minutes.
3.Stop use of contacts until the eye is healed.
4.Encourage good hygiene for prevention of recurrent episodes.
C.Pharmaceutical therapy:
1.Apply erythromycin ophthalmic ointment or azithromycin ophthalmic solution to margin of eye at bedtime, taking care not to contaminate the medication bottle. Bacitracin is an alternative but has been associated with contact dermatitis.
2.Oral antibiotics for severe blepharitis not responding to topical antibiotics: Tetracycline 250 mg by mouth, four times a day for 4 weeks. Alternative: Doxycycline 100 mg by mouth, twice a day, or oxacillin 250 mg four times a day for 4 weeks (contraindicated in pregnancy, lactation).
3.Consider long-term treatment with doxycycline if infections reoccur.
4.Topical glucocorticoids, while having a role in treatment, should be prescribed only by an ophthalmologist because of potential side effects.
Follow-Up
A.Recommend follow-up with primary provider in 1 to 2 weeks.
B.Consider referral to eye specialist for recurrent episodes of blepharitis.
Emergent Issues/Instructions
A.Same-day referral to an ophthalmologist should be arranged for patients with severe eye pain, redness, light sensitivity, vision changes, corneal concerns, or symptoms not responding to initial therapy.
Individual Considerations
A.Geriatrics:
1.If symptoms are unilateral only, patient should be evaluated by an ophthalmologist, as blepharitis is a bilateral condition. Unilateral cases may be associated with malignancy.
2.Azithromycin may lead to abnormalities of heart electrical rhythm; use with caution in patients
with a high risk of cardiovascular disease.
3.Geriatrics that often rub their eyes and have a history of Meibomian gland dysfunction or keratoconus (thinning, protruding cornea) will tend to suffer from blepharitis disease progression. Erythromycin ointment is recommended as a first-line treatment if staphylococcal infection is present. Keep eyes moistened during the day with artificial tear formulations, and ophthalmic gel solutions at night (e.g., Systane® gel drop lubricant).