Blepharitis
Encyclopedia
Blepharitis is an ocular condition characterized by chronic inflammation
of the eyelid
, the severity and time course of which can vary. Onset can be acute, resolving without treatment within 2–4 weeks (this can be greatly reduced with lid hygiene), but more generally is a long standing inflammation varying in severity. It may be classified as seborrhoeic, staphylococcal, mixed, posterior or meiobomitis, or parasitic.
Common signs and symptoms of blepharitis also include itching, irritation
and burning as well as a foreign body sensation. Some patients experience eye dryness, which can cause a certain degree of discomfort
.
People who wear contact lens
es usually have more trouble in coping with their symptoms because although they need contact-lenses, they cannot wear them. Many such patients complain of being unable to wear their lenses for long periods of time or that the lenses are causing them even more irritation of the eye.
Also, the lids may become red and may have ulcerative, non-healing areas which may actually bleed
. Blepharitis does not tend to cause problems with the patient's vision whatsoever, but due to a poor tear film, one may experience blurred vision
.
Eye redness and swelling tend to appear in more advanced cases, and they are rarely primary symptoms. The symptoms can slightly vary based on the exact cause of the condition. Blepharitis due to an allergy
can cause dark lids, symptom which is known as "allergic shiner" and which tends to be more frequent in child
ren rather than adults. Infectious blepharitis is accompanied by a yellow- or green-colored discharge which is more abundant in the morning
and which leads to stuck lids. Blepharitis may also cause eyelid matting or "gluing" of the lashes. Not least, dandruff
may occur on the scalp or on the eyebrows.
Other blepharitis symptoms include sensitivity to light
, eyelashes that grow abnormally or even loss of eyelashes. Also, the tears
might seem frothy or bubbly in nature and mild scarring might occur to the eyelids. The symptoms and signs of blepharitis are often erroneously ascribed by the patient as being due to "recurrent conjunctivitis".
Blepharitis that localizes in the skin of the eyelids may cause stye
s or chalazia, which appear like red bumps, sometimes with a yellow spot if infection
is present. Although pain
is not common among blepharitis symptoms, if the condition persists or becomes painful, the individual is recommended to seek medical attention.
Chronic blepharitis may result in damage of varying severity which may have a negative effect upon vision and therefore upon the eyeglass prescription
.
Infectious blepharitis can cause hard crusts around the eyelashes which leave small ulcers that may bleed or ooze after cleaning.
As a general rule, blepharitis symptoms which do not improve, despite good hygiene
consisting of proper cleaning and care of the eye area, should be referred to a doctor.
. As the infection progresses, the sufferer may begin to notice a foreign body
sensation, matting of the lashes, and burning. Usually, the primary care
physician
will prescribe
topical antibiotics for staphylococcal blepharitis, as this is an acute condition and should heal quickly. The condition can sometimes lead to a chalazion
or a stye
.
Staphylococcal blepharitis is a more severe condition which may start in childhood
and continue through adulthood. It is commonly recurrent and it requires special medical care. The prevalence of Staphylococcus aureus in the conjunctival sac and on the lid margin varies among countries, apparently according to climate
.
In cases of blepharitis caused by Staphylococcus aureus, the presence of a collarette (a ring-like formation around the lash shaft) can be observed. This is the main sign of this particular condition. Other specific symptoms include loss of eyelashes or broken eyelashes.
Staphylococcal blepharitis is mainly diagnosed upon the patient's medical history
and a bacterial culture. However, since blepharitis is a condition that is completely understood, diagnosis usually consists of establishing an accurate medical history of the patient and a proper physical examination
. Blepharitis is diagnosed primarily upon physical examination and rarely further tests are needed. Yet, it is recommended that older patients or those who are at risk of developing certain skin conditions undergo biopsy
in order to remove the possibility of tumor
.
This type of blepharitis is more likely to occur in individuals who are exposed to bacteria
. Staphylococcal blepharitis, unlike the other types of this condition, seems to be seen more frequently in women than men.
It is important that this type of blepharitis is properly treated because otherwise the infection may spread to other parts of the eye or to the scarring of the cornea
. Staphylococcal blepharitis is normally treated with antibiotics such as Chloramphenicol ointment. Fusidic acid is usually the choice of antibiotics in cases when Chloramphenicol is contraindicated. Antibiotics are given for at least four weeks and up to six weeks, which is considered enough so the infection is completely cured. Also, blepharitis treatment includes a short course of topical steroid
s which are administered to control the inflammation.
Staphylococcal blepharitis, along with the other types of blepharitis treatment is only effective if given at the same time with extra cautious eyelid hygiene. This consists of eyelid proper cleaning and removing crusts and debris and maintaining the hygiene by avoiding expired make up or cosmetics that are used around the eye. Particularly in blepharitis caused by S. aureus, patients are recommended to keep the eyelids area clean to avoid spreading the infection when oozing and bleeding occur.
skin type. The oil glands in the lid of rosacea sufferers secrete a modified oil which leads to inflammation at the meibomian gland openings which are found at the edge of the lid.
A typical lid margin hygiene routine consists of four steps:
An alternative after washing is to coat the eyelids with a good quality hair conditioner. Leave in place for several minutes then rinse. The conditioner seems to break the bacteria / crusting /irritation cycle, and daily use can eliminate the symptoms.
The following guide is very common but is more challenging to perform by visually disabled or frail patients as it requires good motor skills and a mirror. Compared with the above, it does not bear any advantages:
Often the above is advised together with mild massage to mechanically empty glands located at the lid margin (Meibomian glands, Zeis glands
, Moll glands
).
Dermatologists treat blepharitis similarly to seborrhoeic dermatitis by using a safe topical anti-inflammatory medication like sulfacetamide
or brief courses of a mild topical steroid. Although anti-fungals like ketoconazole
(Nizoral) are commonly prescribed for seborrhoeic dermatitis, dermatologists and optometrists usually do not prescribe anti-fungals for seborrhoeic blepharitis.
If these conventional treatments for blepharitis do not bring relief, patients may consider allergy testing and ocular antihistamines. Allergic responses to dust mite feces and other allergens can cause lid inflammation, ocular irritation, and dry eyes. Prescription ocular antihistamines and over-the-counter ocular antihistamines are very safe and can bring almost immediate relief to patients whose lid inflammation is caused by allergies.
Small studies have shown N-acetylcysteine supplementation to be of benefit to sufferers of blepharitis.
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the eyelid
Eyelid
An eyelid is a thin fold of skin that covers and protects an eye. With the exception of the prepuce and the labia minora, it has the thinnest skin of the whole body. The levator palpebrae superioris muscle retracts the eyelid to "open" the eye. This can be either voluntarily or involuntarily...
, the severity and time course of which can vary. Onset can be acute, resolving without treatment within 2–4 weeks (this can be greatly reduced with lid hygiene), but more generally is a long standing inflammation varying in severity. It may be classified as seborrhoeic, staphylococcal, mixed, posterior or meiobomitis, or parasitic.
Signs and symptoms
Signs and symptoms that are associated with the chronic inflammation can be:- Redness of the eyelids.
- Flaking of skin on the lids.
- Crusting at the lid margins, this is generally worse on waking.
- Cysts at the lid margin (hordeolum).
- Red eye.
- Debris in the tear film, seen under magnification (improved contrast with use of fluoresceinFluoresceinFluorescein is a synthetic organic compound available as a dark orange/red powder soluble in water and alcohol. It is widely used as a fluorescent tracer for many applications....
drops). - Gritty sensation of the eye.
- Reduced vision.
Common signs and symptoms of blepharitis also include itching, irritation
Irritation
Irritation or exacerbation, in biology and physiology, is a state of inflammation or painful reaction to allergy or cell-lining damage. A stimulus or agent which induces the state of irritation is an irritant...
and burning as well as a foreign body sensation. Some patients experience eye dryness, which can cause a certain degree of discomfort
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
.
People who wear contact lens
Contact lens
A contact lens, or simply contact, is a lens placed on the eye. They are considered medical devices and can be worn to correct vision, for cosmetic or therapeutic reasons. In 2004, it was estimated that 125 million people use contact lenses worldwide, including 28 to 38 million in the United...
es usually have more trouble in coping with their symptoms because although they need contact-lenses, they cannot wear them. Many such patients complain of being unable to wear their lenses for long periods of time or that the lenses are causing them even more irritation of the eye.
Also, the lids may become red and may have ulcerative, non-healing areas which may actually bleed
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
. Blepharitis does not tend to cause problems with the patient's vision whatsoever, but due to a poor tear film, one may experience blurred vision
Blurred vision
-Causes:There are many causes of blurred vision:* Use of atropine or other anticholinergics* Presbyopia -- Difficulty focusing on objects that are close. The elderly are common victims....
.
Eye redness and swelling tend to appear in more advanced cases, and they are rarely primary symptoms. The symptoms can slightly vary based on the exact cause of the condition. Blepharitis due to an allergy
Allergy
An Allergy is a hypersensitivity disorder of the immune system. Allergic reactions occur when a person's immune system reacts to normally harmless substances in the environment. A substance that causes a reaction is called an allergen. These reactions are acquired, predictable, and rapid...
can cause dark lids, symptom which is known as "allergic shiner" and which tends to be more frequent in child
Child
Biologically, a child is generally a human between the stages of birth and puberty. Some vernacular definitions of a child include the fetus, as being an unborn child. The legal definition of "child" generally refers to a minor, otherwise known as a person younger than the age of majority...
ren rather than adults. Infectious blepharitis is accompanied by a yellow- or green-colored discharge which is more abundant in the morning
Morning
The word morning originally referred to the sunrise. Morning precedes midday, afternoon, and night in the sequence of a day.Morning is the part of the day usually reckoned from dawn to noon...
and which leads to stuck lids. Blepharitis may also cause eyelid matting or "gluing" of the lashes. Not least, dandruff
Dandruff
Dandruff is the shedding of dead skin cells from the scalp . Dandruff is sometimes caused by frequent exposure to extreme heat and cold. As it is normal for skin cells to die and flake off, a small amount of flaking is normal and common; about 487,000 cells/cm2 get released normally after...
may occur on the scalp or on the eyebrows.
Other blepharitis symptoms include sensitivity to light
Light
Light or visible light is electromagnetic radiation that is visible to the human eye, and is responsible for the sense of sight. Visible light has wavelength in a range from about 380 nanometres to about 740 nm, with a frequency range of about 405 THz to 790 THz...
, eyelashes that grow abnormally or even loss of eyelashes. Also, the tears
Tears
Tears are secretions that clean and lubricate the eyes. Lacrimation or lachrymation is the production or shedding of tears....
might seem frothy or bubbly in nature and mild scarring might occur to the eyelids. The symptoms and signs of blepharitis are often erroneously ascribed by the patient as being due to "recurrent conjunctivitis".
Blepharitis that localizes in the skin of the eyelids may cause stye
Stye
An external stye or sty , also hordeolum , is an infection of the sebaceous glands of Zeis at the base of the eyelashes, or an infection of the apocrine sweat glands of Moll. External styes form on the outside of the lids and can be seen as small red bumps. Internal styes are infections of the...
s or chalazia, which appear like red bumps, sometimes with a yellow spot if infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
is present. Although pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
is not common among blepharitis symptoms, if the condition persists or becomes painful, the individual is recommended to seek medical attention.
Chronic blepharitis may result in damage of varying severity which may have a negative effect upon vision and therefore upon the eyeglass prescription
Eyeglass prescription
An eyeglass prescription is an order written by an eyewear prescriber, such as an optometrist or ophthalmologist, that specifies the value of all parameters the prescriber has deemed necessary to construct and/or dispense corrective lenses appropriate for a patient.If an examination indicates that...
.
Infectious blepharitis can cause hard crusts around the eyelashes which leave small ulcers that may bleed or ooze after cleaning.
As a general rule, blepharitis symptoms which do not improve, despite good hygiene
Hygiene
Hygiene refers to the set of practices perceived by a community to be associated with the preservation of health and healthy living. While in modern medical sciences there is a set of standards of hygiene recommended for different situations, what is considered hygienic or not can vary between...
consisting of proper cleaning and care of the eye area, should be referred to a doctor.
Staphylococcal blepharitis
Staphylococcal blepharitis is caused by infection of the anterior portion of the eyelid by Staphylococcal bacteriaStaphylococcus
Staphylococcus is a genus of Gram-positive bacteria. Under the microscope they appear round , and form in grape-like clusters....
. As the infection progresses, the sufferer may begin to notice a foreign body
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
sensation, matting of the lashes, and burning. Usually, the primary care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...
physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
will prescribe
Medical prescription
A prescription is a health-care program implemented by a physician or other medical practitioner in the form of instructions that govern the plan of care for an individual patient. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist or other therapist....
topical antibiotics for staphylococcal blepharitis, as this is an acute condition and should heal quickly. The condition can sometimes lead to a chalazion
Chalazion
A chalazion , also known as a meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid. Chalazia differ from styes in that they are subacute and usually painless nodules...
or a stye
Stye
An external stye or sty , also hordeolum , is an infection of the sebaceous glands of Zeis at the base of the eyelashes, or an infection of the apocrine sweat glands of Moll. External styes form on the outside of the lids and can be seen as small red bumps. Internal styes are infections of the...
.
Staphylococcal blepharitis is a more severe condition which may start in childhood
Childhood
Childhood is the age span ranging from birth to adolescence. In developmental psychology, childhood is divided up into the developmental stages of toddlerhood , early childhood , middle childhood , and adolescence .- Age ranges of childhood :The term childhood is non-specific and can imply a...
and continue through adulthood. It is commonly recurrent and it requires special medical care. The prevalence of Staphylococcus aureus in the conjunctival sac and on the lid margin varies among countries, apparently according to climate
Climate
Climate encompasses the statistics of temperature, humidity, atmospheric pressure, wind, rainfall, atmospheric particle count and other meteorological elemental measurements in a given region over long periods...
.
In cases of blepharitis caused by Staphylococcus aureus, the presence of a collarette (a ring-like formation around the lash shaft) can be observed. This is the main sign of this particular condition. Other specific symptoms include loss of eyelashes or broken eyelashes.
Staphylococcal blepharitis is mainly diagnosed upon the patient's medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
and a bacterial culture. However, since blepharitis is a condition that is completely understood, diagnosis usually consists of establishing an accurate medical history of the patient and a proper physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
. Blepharitis is diagnosed primarily upon physical examination and rarely further tests are needed. Yet, it is recommended that older patients or those who are at risk of developing certain skin conditions undergo biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
in order to remove the possibility of tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
.
This type of blepharitis is more likely to occur in individuals who are exposed to bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
. Staphylococcal blepharitis, unlike the other types of this condition, seems to be seen more frequently in women than men.
It is important that this type of blepharitis is properly treated because otherwise the infection may spread to other parts of the eye or to the scarring of the cornea
Cornea
The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Together with the lens, the cornea refracts light, with the cornea accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is...
. Staphylococcal blepharitis is normally treated with antibiotics such as Chloramphenicol ointment. Fusidic acid is usually the choice of antibiotics in cases when Chloramphenicol is contraindicated. Antibiotics are given for at least four weeks and up to six weeks, which is considered enough so the infection is completely cured. Also, blepharitis treatment includes a short course of topical steroid
Topical steroid
Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. Topical steroids have anti-inflammatory properties, and are classified based on their vasoconstriction abilities. There...
s which are administered to control the inflammation.
Staphylococcal blepharitis, along with the other types of blepharitis treatment is only effective if given at the same time with extra cautious eyelid hygiene. This consists of eyelid proper cleaning and removing crusts and debris and maintaining the hygiene by avoiding expired make up or cosmetics that are used around the eye. Particularly in blepharitis caused by S. aureus, patients are recommended to keep the eyelids area clean to avoid spreading the infection when oozing and bleeding occur.
Posterior blepharitis or rosacea-associated blepharitis
The most common type of blepharitis is often found in people with a RosaceaRosacea
Rosacea is a chronic condition characterized by facial erythema . Pimples are sometimes included as part of the definition. Unless it affects the eyes, it is typically a harmless cosmetic condition...
skin type. The oil glands in the lid of rosacea sufferers secrete a modified oil which leads to inflammation at the meibomian gland openings which are found at the edge of the lid.
Treatment and management
The single most important treatment principle is a daily routine of lid margin hygiene, as described below. Such a routine needs to be convenient enough to be continued for life to avoid relapses as blepharitis is often a chronic condition. But it can be acute, and one episode does not mean it is a life-long condition.A typical lid margin hygiene routine consists of four steps:
- Softening of lid margin debris and oils: Apply a warm wet compress to the lids - such as a washcloth with hot water - for about two minutes. New, dry, warm compress masks can be conveniently warmed in a micro-wave oven and maintain a comfortable 40C temperature for 10 minutes while the waxy oils blocking the glands are cleared.
- Mechanical removal of lid margin debris: At the end of a shower routine, wash your face with a wash cloth. Use facial soapCleanserA cleanser is a product used to cleanse something, such as a detergent or industrial cleaning agent.A popular type of cleanser is a facial care product that is used to remove make-up, dead skin cells, oil, dirt, and other types of pollutants from the skin of the face...
or non-burning baby shampoo (make sure to dilute the soap solution 1/10 with water first). Gently and repeatedly rub along the lid margins while eyes are closed. Too much soap or shampoo may remove the essential oily layer of the eyes' own tear film and create further problems with dry eye discomfort. - Antibiotic reduction of lid margin bacteria (at the discretion of a physician): After lid margin cleaning, spread small amount of prescription antibiotic ophthalmic ointment with finger tip along lid fissure while eyes closed. Use prior to bed time as opposed to in the morning to avoid blurry vision.
- Avoid the use of eye make-up until symptoms subside.
An alternative after washing is to coat the eyelids with a good quality hair conditioner. Leave in place for several minutes then rinse. The conditioner seems to break the bacteria / crusting /irritation cycle, and daily use can eliminate the symptoms.
The following guide is very common but is more challenging to perform by visually disabled or frail patients as it requires good motor skills and a mirror. Compared with the above, it does not bear any advantages:
- Apply hot compresses to both eyes for five minutes once to twice per day. The "hot wet flannel" treatment is often recommended, however this does not stay hot for long enough, is very messy & potentially unhygienic. A very effective alternative is a flax filled mask which is heated in a microwave oven.
- After hot compresses, in front of a mirror, use a moist cotton bud soaked in a cup of water with a drop of baby shampoo, or a drop of antibiotic such as Chloramphenicol. Rub along the lid margins while tilting the lid outward with the other hand.
- In front of mirror, place small drop of antibiotic ophthalmic ointment (e.g. erythromycinErythromycinErythromycin is a macrolide antibiotic that has an antimicrobial spectrum similar to or slightly wider than that of penicillin, and is often used for people who have an allergy to penicillins. For respiratory tract infections, it has better coverage of atypical organisms, including mycoplasma and...
) in lower conjunctival sac while pulling lid away from eye with other hand.
Often the above is advised together with mild massage to mechanically empty glands located at the lid margin (Meibomian glands, Zeis glands
Glands of Zeis
Glands of Zeis are unilobar sebaceous glands located on the margin of the eyelid. The glands of Zeis service the eyelash. These glands produce an oily substance that is issued through the excretory ducts of the sebaceous lobule into the middle portion of the hair follicle...
, Moll glands
Glands of Moll
Glands of Moll, also known as ciliary glands, are modified apocrine sweat glands that are found on the margin of the eyelid. They are next to the base of the eyelashes, and anterior to the Meibomian glands within the distal eyelid margin. These glands are relatively large and tubular-shaped.Moll's...
).
Dermatologists treat blepharitis similarly to seborrhoeic dermatitis by using a safe topical anti-inflammatory medication like sulfacetamide
Sulfacetamide
Sulfacetamide is a sulfonamide antibiotic.-Uses:Sulfacetamide 10% topical lotion, sold under the brand name Klaron or Ovace, is approved for the treatment of acne and seborrheic dermatitis. When combined with sulfur, it is sold under the brand names Plexion, Clenia, Prascion, and Avar, which...
or brief courses of a mild topical steroid. Although anti-fungals like ketoconazole
Ketoconazole
Ketoconazole is a synthetic antifungal drug used to prevent and treat fungal skin infections, especially in immunocompromised patients such as those with AIDS or those on chemotherapy. Ketoconazole is sold commercially as an anti-dandruff shampoo, topical cream, and oral tablet.Ketoconazole is...
(Nizoral) are commonly prescribed for seborrhoeic dermatitis, dermatologists and optometrists usually do not prescribe anti-fungals for seborrhoeic blepharitis.
If these conventional treatments for blepharitis do not bring relief, patients may consider allergy testing and ocular antihistamines. Allergic responses to dust mite feces and other allergens can cause lid inflammation, ocular irritation, and dry eyes. Prescription ocular antihistamines and over-the-counter ocular antihistamines are very safe and can bring almost immediate relief to patients whose lid inflammation is caused by allergies.
Small studies have shown N-acetylcysteine supplementation to be of benefit to sufferers of blepharitis.
See also
- Seborrhoeic dermatitisSeborrhoeic dermatitisSeborrhoeic dermatitis is an inflammatory skin disorder affecting the scalp, face, and torso. Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin. It particularly affects the sebaceous-gland-rich areas of skin...
- List of skin diseases
- List of eye diseases and disorders
- StyeStyeAn external stye or sty , also hordeolum , is an infection of the sebaceous glands of Zeis at the base of the eyelashes, or an infection of the apocrine sweat glands of Moll. External styes form on the outside of the lids and can be seen as small red bumps. Internal styes are infections of the...
- ChalazionChalazionA chalazion , also known as a meibomian gland lipogranuloma, is a cyst in the eyelid that is caused by inflammation of a blocked meibomian gland, usually on the upper eyelid. Chalazia differ from styes in that they are subacute and usually painless nodules...
- ConjunctivitisConjunctivitisConjunctivitis refers to inflammation of the conjunctiva...
External links
- Blepharitis Resource Guide from the National Eye Institute (NEI).
- Mayo Clinic
- Blepharitis description from the American Optometric Association
- eMedicine Health: Eyelid Inflammation (Blepharitis)
- Blepharitis Fact Sheet