Blepharitis

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Blepharitis
Infant with blepharitis on the right side.jpg
An infant with mild blepharitis on his right side
Pronunciation
Specialty Ophthalmology, Optometry
Symptoms crusty eyelids

Blepharitis, sometimes known as granulated eyelids, is one of the most common ocular conditions characterized by inflammation, scaling, reddening, and crusting of the eyelid. This condition may also cause swelling, burning, itching, or a grainy sensation when introducing foreign objects or substances to the eye. Although blepharitis by itself is not sight-threatening, it can lead to permanent alterations of the eyelid margin. The primary cause is bacteria and inflammation from congested meibomian oil glands at the base of each eyelash. Other conditions may give rise to blepharitis, whether they be infectious or noninfectious, including, but not limited to, bacterial infections or allergies.

Contents

Different variations of blepharitis can be classified as seborrheic, staphylococcal, mixed, posterior or meibomitis, or parasitic. [1] In a survey of US ophthalmologists and optometrists, 37% to 47% of patients seen by those surveyed had signs of blepharitis, which can affect all ages and ethnic groups. [2] One single-center study of 90 patients with chronic blepharitis found that the average age of patients was 50 years old. [2] The word is from Greek βλέφαρον (blepharon) 'eyelid'and -itis 'inflammation of'.

Signs and symptoms

Blepharitis is characterized by chronic inflammation of the eyelid, usually at the base of the eyelashes. [3] [4] [5] Symptoms include inflammation, irritation, itchiness, a burning sensation, excessive tearing, and crusting and sticking of eyelids. [3] [4] Additional symptoms may include visual impairment such as photophobia and blurred vision. Symptoms are generally worse in the mornings and patients may experience exacerbation and several remissions if left untreated. [2] It is typically caused by bacterial infection or blockage of the meibomian oil glands. [4] Diseases and conditions that may lead to blepharitis include: rosacea, herpes simplex dermatitis, varicella-zoster dermatitis, molluscum contagiosum, allergic dermatitis, contact dermatitis, seborrheic dermatitis, staphylococcal dermatitis, demodicosis (Demodex), and parasitic infections (e.g., Demodex and Phthiriasis palpebrarum). [2] [3] [5]

The parasite Demodex folliculorum (D. folliculorum) causes blepharitis when the parasite is present in excessive numbers within the dermis of the eyelids. These parasites can live for approximately 15 days. The parasites (both adult and eggs) live on the hair follicle, inhabiting the sebaceous and apocrine gland of the human lid. Direct contact allows this pathogen to spread. Factors that allow this pathogen to multiply include hypervascular tissue, poor hygienic conditions, and immune deficiency. In treating blepharitis caused by D. folliculorum, mechanical cleaning and proper hygiene are important towards decreasing the parasite's numbers.  [6]

Scaling and bacterial debris at the base of the eyelashes Anterior Blepharitis.jpg
Scaling and bacterial debris at the base of the eyelashes

Associated symptoms

Chalazion Internal hordeolum.jpg
Chalazion

Chronic blepharitis may result in damage of varying severity and, in the worst cases, may have a negative effect on vision. This can be resolved with a proper eyeglass prescription. [8] Long-term untreated blepharitis can lead to eyelid scarring, excess tearing, difficulty wearing contact lenses, development of a stye (an infection near the base of the eyelashes, resulting in a painful lump on the edge of the eyelid) or a chalazion (a blockage/bacteria infection in a small oil gland at the margin of the eyelid, just behind the eyelashes, leading to a red, swollen eyelid), chronic pink eye (conjunctivitis), keratitis, and corneal ulcer or irritation. [4] [9] [5] The lids may become red and may have ulcerate, non-healing areas that may lead to bleeding. [8] Blepharitis can also cause blurred vision due to a poor tear film. [4] Tears may be frothy or bubbly, which can contribute to mild scarring along the eyelids. Symptoms and signs of blepharitis are often erroneously ascribed by the patient to "recurrent conjunctivitis". [10]

Subtype symptoms

General symptoms include a foreign body sensation, matting of the lashes, and burning. Collarette around eyelashes, a ring-like formation around the lash shaft, can be observed. [5] Other symptoms include loss of eyelashes or broken eyelashes. [11] The condition can sometimes lead to a chalazion or a stye. [12] Chronic bacterial blepharitis may also lead to ectropion. [13] Posterior blepharitis or rosacea-associated blepharitis is manifested by a broad spectrum of symptoms involving the lids including inflammation and plugging of the meibomian orifices and production of abnormal secretion upon pressure over the glands. [1]

Mechanism

The mechanism by which the bacteria causes symptoms of blepharitis is not fully understood and may include direct irritation of bacterial toxins and/or enhanced cell-mediated immunity to S. aureus .

Staphylococcal blepharitis is caused by an infection of the anterior portion of the eyelid by Staphylococcal bacteria. [14] In a study of ocular flora, 46% to 51% of those diagnosed with staphylococcal blepharitis had cultures positive for Staphylococcus aureus in comparison to 8% of normal patients. [2] Staphylococcal blepharitis may start in childhood and continue into adulthood. [15] It is commonly recurrent and it requires special medical care. The prevalence of S. aureus in the conjunctival sac and on the lid margin varies among countries, likely due to differences in climate and environment. [14] Seborrheic blepharitis is characterized by less inflammation than Staphylococcal blepharitis; however, it causes more excess oil or greasy scaling. Meibomian gland dysfunction is a result of abnormalities of the meibomian glands and altered secretion of meibum, which plays an imperative role in lagging the evaporation of tear films and smoothing of the tear film to produce an even optical surface. Posterior blepharitis is an inflammation of the eyelids, secondary to dysfunction of the meibomian glands. Like anterior blepharitis, it is a bilateral chronic condition and may be associated with skin rosacea. [1] There is growing evidence that, in some cases, it is caused by demodex mites. [16]

Diagnosis

Blepharitis: swollen and reddened eyelid Blepharitis.JPG
Blepharitis: swollen and reddened eyelid

Diagnosis of the condition is done via a physical examination under a slit lamp. Cultures of debris are occasionally collected for bacterial or fungal testing. [17] [5]

Examination

In all forms of blepharitis, optometrists or ophthalmologists examine the tear film, which is the most efficient method in determining instability. The most frequently used method is to measure tear production via tear break-up time (TBUT), which calculates the duration interval between complete blinks. This serves as a primary indication of regional dryness in the pre-corneal tear film after fluorescein injections. If TBUT is shorter than 10 seconds, then this suggests instability. [2]

Staphylococcal blepharitis is diagnosed by examining erythema and edema of the eyelid margin. Patients may exhibit alopecia areata of eyelashes and/or growth misdirection, trichiasis. Other signs may include telangiectasia on the anterior eyelid, collarettes encircling the lash base, and corneal changes. [2] Seborrheic blepharitis is distinguished by less erythema, edema, and telangiectasia of the eyelid margins. Posterior blepharitis and Meibomian gland dysfunction are frequently associated with rosacea and can be seen during an ocular examination of the posterior eyelid margin. The Meibomian glands may appear caked with oil or visibly obstructed. [2]

Procedures

Cultures of the eyelid margins can be a clear indicator for patients who have recurrent anterior blepharitis with severe inflammation, in addition to patients who are not responding to therapy. [2] Measurements of tear osmolarity may be beneficial in diagnosing concurrent dry eye syndrome (DES), which may be responsible for overlapping symptoms and would allow the physician to decipher between conditions and move forward with the most beneficial protocol for the patient. Consequently, the measurement of tear osmolarity has various limitations in differentiating between aqueous deficiencies and evaporative dry eye. [18] Microscopic evaluation of epilated eyelashes may reveal mites, which have been evident in cases of chronic blepharoconjunctivitis. A biopsy of the eyelid can also determine the exclusion of carcinoma, therapy resistance, or unifocal recurrent chalazia. [19]

ConditionEntity
Bacterial infections Erysipelas (due to Streptococcus pyogenes)

Impetigo (due to Staphylococcus aureus)

Viral infections Herpes simplex virus

Molluscum contagiosum

Varicella zoster virus

Papillomavirus

Vaccinia

Parasitic infectionPediculosis palperbrarum
Immunologic conditions Atopic dermatitis

Contact dermatitis

Erythema multiforme

Crohn's disease

Dermatoses Psoriasis

Erythroderma

Benign eyelid tumors Actinic keratosis

Pyogenic granuloma

Malignant eyelid tumors Melanoma

Mycosis fungoides

Basal cell carcinoma

Trauma Chemical

Radiation

Surgical

Thermal

Toxic conditionsMedicamentosa

Prevention

Blepharitis is a result of bacteria and inflammation from congested meibomian oil glands at the base of each eyelash. Routine washing of the eyelids helps subdue symptoms and prevent blepharitis. Washing each eyelid for 30 seconds, twice a day, with a single drop of hypoallergenic soap (e.g. baby shampoo) and ample water can help. The most effective treatment is over the counter lid scrubs used twice a day. Some doctors may recommend using a hypochlorous acid treatment depending on the severity. [2]

Treatment

Microwavable warm compresses for daily loop treatment Warm compress.jpg
Microwavable warm compresses for daily loop treatment

Blepharitis is a chronic condition causing frequent exacerbation, thus requiring routine eyelid hygiene. Hygienic practices include warm compresses, eyelid massages, and eyelid scrubs. [2] A Cochrane Systematic Review found topical antibiotics to be effective in providing symptomatic relief and clearing bacteria for individuals with anterior blepharitis. [20] Topical steroids provided some symptomatic relief, but they were ineffective in clearing bacteria from the eyelids. [20] Lid hygiene measures such as warm compresses and lid scrubs were found to be effective in providing symptomatic relief for participants with anterior and posterior blepharitis. [20]

Lotilaner (Xdemvy) was approved for medical use in the United States in July 2023, for the treatment of Demodex blepharitis. [21]

Prognosis

Blepharitis is a chronic condition that has periods of exacerbation and remission. Patients should be informed that symptoms can frequently improve but are rarely eliminated. Infrequently, severe blepharitis can result in permanent alterations in the eyelid margin or vision loss from superficial keratopathy, corneal neovascularization, and ulceration. Patients with an inflammatory eyelid lesion that appears suspicious of malignancy should be referred to an appropriate specialist. [2] [10]

Research

A study conducted in November 2017 detected a correlation between blepharitis and early-onset metabolic syndrome (MetS). To investigate the relationship between blepharitis and MetS, researchers used the Longitudinal Health Insurance Database in Taiwan. Results indicated that hyperlipidaemia and coronary artery disease were significantly correlated with the prior development of blepharitis. Therefore, blepharitis was shown to be significantly related to MetS and can serve as an early indication of the condition. [22]

In another study, the presence of Demodex mites was shown to be a common cause of blepharitis. However, the pathogenesis of demodicosis is still unclear. In this study, researchers provided a diagnosis of the disease and proposed diagnostic criteria for Demodex blepharitis.

There is inadequate evidence to draw conclusions about the use of oral doxycycline in the treatment of blepharitis. According to very low certainty data, oral doxycycline may help with symptoms like itchiness, burning, or watery eyes, but may induce more side effects. [23]

A review of treatments showed that the anti-mite drug ivermectin can be an effective treatment for reducing symptoms. [24]

Eye drops or ointments containing corticosteroids are frequently used in conjunction with antibiotics and can reduce eyelid inflammation. [4] [5] [25]

The supplement n-acetylcysteine may be effective for blepharitis. [26]

Related Research Articles

<span class="mw-page-title-main">Conjunctivitis</span> Inflammation of the eye

Conjunctivitis, also known as pink eye, is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid. It makes the eye appear pink or reddish. Pain, burning, scratchiness, or itchiness may occur. The affected eye may have increased tears or be "stuck shut" in the morning. Swelling of the white part of the eye may also occur. Itching is more common in cases due to allergies. Conjunctivitis can affect one or both eyes.

<span class="mw-page-title-main">Sebaceous gland</span> Gland to lubricate the hair and skin

A sebaceous gland or oil gland is a microscopic exocrine gland in the skin that opens into a hair follicle to secrete an oily or waxy matter, called sebum, which lubricates the hair and skin of mammals. In humans, sebaceous glands occur in the greatest number on the face and scalp, but also on all parts of the skin except the palms of the hands and soles of the feet. In the eyelids, meibomian glands, also called tarsal glands, are a type of sebaceous gland that secrete a special type of sebum into tears. Surrounding the female nipples, areolar glands are specialized sebaceous glands for lubricating the nipples. Fordyce spots are benign, visible, sebaceous glands found usually on the lips, gums and inner cheeks, and genitals.

<span class="mw-page-title-main">Demodicosis</span> Animal disease caused by hosting of mites (genus Demodex)

Demodicosis, also called Demodex folliculitis in humans and demodectic mange or red mange in animals, is caused by a sensitivity to and overpopulation of Demodex spp. as the host's immune system is unable to keep the mites under control.

<span class="mw-page-title-main">Eyelid</span> Thin fold of skin that covers and protects the eye

An eyelid is a thin fold of skin that covers and protects an eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. "Palpebral" means relating to the eyelids. Its key function is to regularly spread the tears and other secretions on the eye surface to keep it moist, since the cornea must be continuously moist. They keep the eyes from drying out when asleep. Moreover, the blink reflex protects the eye from foreign bodies. A set of specialized hairs known as lashes grow from the upper and lower eyelid margins to further protect the eye from dust and debris.

<span class="mw-page-title-main">Rosacea</span> Skin condition, usually on the face

Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarged nose may occur in severe disease, a condition known as rhinophyma.

<span class="mw-page-title-main">Dry eye syndrome</span> Medical condition of dry eyes

Dry eye syndrome, also known as keratoconjunctivitis sicca, is the condition of having dry eyes. Symptoms include dryness in the eye, irritation, redness, discharge, blurred vision, and easily fatigued eyes. Symptoms range from mild and occasional to severe and continuous. Dry eye syndrome can lead to blurred vision, instability of the tear film, increased risk of damage to the ocular surface such as scarring of the cornea, and changes in the eye including the neurosensory system.

<span class="mw-page-title-main">Eyelash</span> Facial feature

An eyelash is one of the hairs that grows at the edges of the top and bottom eyelids, spanning outwards and away from the eyes. The lashes grow in up to six layers on each of the upper and lower eyelids. Eyelashes serve to protect the eye from debris, dust, and small particles, and are highly sensitive to touch, thus providing a warning that an object is near the eye, which then reflexively closes or flutters to rid the area of the object. The eyelid margin from which lashes grow is among the most sensitive parts of the human body, with many nerve endings enveloping the roots of the lashes, giving it sensitivity to very light tactile input even at the tips of the lashes, enabling it to trigger the blink reflex when touched. Eyelashes are also an important component of physical attractiveness, with long prominent lashes giving the illusion of large, gazing eyes, and drawing attention to the eyes.

<span class="mw-page-title-main">Chalazion</span> Inflammatory swelling of the eyelid due to meibomian gland blockage

A chalazion or meibomian cyst is not a cyst but a granuloma in the eyelid that results from a blocked meibomian gland. It typically occurs in the middle of the eyelid, red, and not painful. They tend to come on gradually over a few weeks.

<span class="mw-page-title-main">Stye</span> Swelling of the eyelid due to infection of an oil gland

A stye, also known as a hordeolum, is a bacterial infection of an oil gland in the eyelid. This results in a red tender bump at the edge of the eyelid. The outside or the inside of the eyelid can be affected.

<i>Demodex</i> Genus of mites that live on mammals

Demodex is a genus of tiny mites that live in or near hair follicles of mammals. Around 65 species of Demodex are known. Two species live on humans: Demodex folliculorum and Demodex brevis, both frequently referred to as eyelash mites, alternatively face mites or skin mites.

<span class="mw-page-title-main">Cradle cap</span> Crusting or scaling of a babys scalp

Cradle cap causes crusty or oily scaly patches on a baby's scalp. The condition is not painful or itchy, but it can cause thick white or yellow scales that are not easy to remove. Cradle cap most commonly begins sometime in the first three months but can occur in later years. Similar symptoms in older children are more likely to be dandruff than cradle cap. The rash is often prominent around the ear, the eyebrows or the eyelids. It may appear in other locations as well, where it is called infantile seborrhoeic dermatitis. Cradle cap is just a special—and more benign—case of this condition. The exact cause of cradle cap is not known. Cradle cap is not spread from person to person (contagious). It is also not caused by poor hygiene. It is not an allergy, and it is not dangerous. Cradle cap often lasts a few months. In some children, the condition can last until age 2 or 3.

<span class="mw-page-title-main">Meibomian gland</span> Sebaceous glands along the rims of the eyelid

Meibomian glands are sebaceous glands along the rims of the eyelid inside the tarsal plate. They produce meibum, an oily substance that prevents evaporation of the eye's tear film. Meibum prevents tears from spilling onto the cheek, traps them between the oiled edge and the eyeball, and makes the closed lids airtight. There are about 25 such glands on the upper eyelid, and 20 on the lower eyelid.

<span class="mw-page-title-main">Distichia</span> Eyelash growth from an abnormal part of the eyelid

A distichia is an eyelash that arises from an abnormal part of the eyelid. This abnormality, attributed to a genetic mutation, is known to affect dogs and humans. Distichiae usually exit from the duct of the meibomian gland at the eyelid margin. They are usually multiple, and sometimes more than one arises from a duct. They can affect either the upper or lower eyelid and are usually bilateral. The lower eyelids of dogs usually have no eyelashes.

Madarosis is a condition that results in the loss of eyelashes, and sometimes eyebrows. The term "madarosis" is derived from the ancient Greek "madaros", meaning "bald". It originally was a disease of only losing eyelashes but it currently is the loss of both eyelashes and eyebrows. Eyebrows and eyelashes are both important in the prevention of bacteria and other foreign objects from entering the eye. A majority of patients with madarosis have leprosy, and it was reported that 76% of patients with varying types of leprosy had madarosis.

Eyelid dermatitis is commonly related to atopic dermatitis or allergic contact dermatitis. Volatile substances, tosylamide, epoxy hardeners, insect sprays, and lemon peel oil may be implicated, with many cases of eyelid contact dermatitis being caused by substances transferred by the hands to the eyelids.

<span class="mw-page-title-main">Sebaceous carcinoma</span> Malignant tumor of oil glands in the skin

Sebaceous carcinoma, also known as sebaceous gland carcinoma (SGc), sebaceous cell carcinoma, and meibomian gland carcinoma, is an uncommon malignant cutaneous (skin) tumor. Most are typically about 1.4 cm at presentation. SGc originates from sebaceous glands in the skin and, therefore, may originate anywhere in the body where these glands are found. SGc can be divided into 2 types: periocular and extraocular. The periocular region is rich in sebaceous glands making it a common site of origin. The cause of these lesions in the vast majority of cases is unknown. Occasional cases may be associated with Muir-Torre syndrome. SGc accounts for approximately 0.7% of all skin cancers, and the incidence of SGc is highest in Caucasian, Asian, and Indian populations. Due to the rarity of this tumor and variability in clinical and histological presentation, SGc is often misdiagnosed as an inflammatory condition or a more common neoplasm. SGc is commonly treated with wide local excision or Mohs micrographic surgery, and the relative survival rates at 5 and 10 years are 92.72 and 86.98%, respectively.

<span class="mw-page-title-main">Conjunctivochalasis</span> Excess folds of the conjunctiva of the eye

Conjunctivochalasis, also known as mechanical dry eye (MDE), is a common eye surface condition characterized by the presence of excess folds of the conjunctiva located between the globe of the eye and the eyelid margin.

<span class="mw-page-title-main">Meibomian gland dysfunction</span> Disease of the meibomian glands of the eyelid

Meibomian gland dysfunction is a chronic disease of the meibomian glands, which is commonly characterized by obstruction of the end of the duct that delivers the secretion produced by the glands to the eye surface, which prevents the glandular secretion from reaching the ocular surface. The dysfunction could be that the amount of secretion produced may be abnormal. Dysfunction could also be related to the quality of the meibum produced. MGD may result in evaporative dry eye, blepharitis, chalazion, unsealed lid during sleep, and meibomian gland atrophy.

BlephEx is a medical device used in the fields of ophthalmology and optometry to treat blepharitis and dry eye disease. The handheld device is used by a doctor to exfoliate the eyelid at the lash line and remove the inflammatory biofilm that leads to chronic lid disease and discomfort.

<span class="mw-page-title-main">Warm compress</span> Method of applying heat to the body

A warm compress is a method of applying heat to the body. Heating sources can include warm water, microwaveable pads, wheat packs and electrical or chemical pads. Some unorthodox methods can include warmed potatoes, uncooked rice, and hard-boiled eggs. The most common warm compress is a warm, wet washcloth.

References

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  6. ↑ Inceboz T, Yaman A, Over L, Ozturk AT, Akisu C (2009). "Diagnosis and treatment of demodectic blepharitis". Turkiye Parazitolojii Dergisi. 33 (1): 32–36. PMID   19367544.
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  18. ↑ Savini G, Prabhawasat P, Kojima T, Grueterich M, Espana E, Goto E (March 2008). "The challenge of dry eye diagnosis". Clinical Ophthalmology. 2 (1): 31–55. doi: 10.2147/opth.s1496 . PMC   2698717 . PMID   19668387.
  19. ↑ Nemoto Y, Arita R, Mizota A, Sasajima Y (September 2014). "Differentiation between chalazion and sebaceous carcinoma by noninvasive meibography". Clinical Ophthalmology. 8: 1869–1875. doi: 10.2147/OPTH.S69804 . PMC   4172083 . PMID   25258508.
  20. 1 2 3 Lindsley K, Matsumura S, Hatef E, Akpek EK (May 2012). "Interventions for chronic blepharitis". The Cochrane Database of Systematic Reviews. 5 (5): CD005556. doi:10.1002/14651858.CD005556.pub2. PMC   4270370 . PMID   22592706.
  21. ↑ "FDA Approves Xdemvy (lotilaner ophthalmic solution) 0.25% for the treatment of Demodex blepharitis" (Press release). Tarsus Pharmaceuticals. 25 July 2023. Retrieved 5 August 2023– via GlobeNewswire.
  22. ↑ Lee CY, Chen HC, Lin HW, Huang JY, Chao SC, Yeh CB, et al. (September 2018). "Blepharitis as an early sign of metabolic syndrome: a nationwide population-based study". The British Journal of Ophthalmology. 102 (9): 1283–1287. doi:10.1136/bjophthalmol-2017-310975. PMID   29146760. S2CID   26261977.
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  24. ↑ Navel V, Mulliez A, Benoist d'Azy C, Baker JS, Malecaze J, Chiambaretta F, Dutheil F (October 2019). "Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis". The Ocular Surface. 17 (4): 655–669. doi: 10.1016/j.jtos.2019.06.004 . PMID   31229586.
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  26. ↑ N-Acetylcysteine in Chronic Blepharitis Yalçin, Elvan M.D.; Altin, Feyza M.D.; Cinhüseyinoglue, Feriha M.D.; Arslan, M. Okan M.D., CLINICAL SCIENCES Cornea 21(2):p 164-168, March 2002, accessed 29 October 2023
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