Key Facts

Blepharitis is a chronic bilateral inflammatory condition affecting the eyelid margins. It is extremely common and often coexists with dry eye disease. Management focuses on long-term lid hygiene to control symptoms rather than cure.

Epidemiology

• One of the most common ocular conditions
• Affects all age groups but more common with increasing age
• Equal sex distribution
• Present in 37-47% of patients attending ophthalmology clinics
• Often underdiagnosed in primary care

Aetiology

• Anterior blepharitis:
  • Staphylococcal: chronic low-grade Staphylococcus aureus or S. epidermidis infection at lash base
  • Seborrhoeic: associated with seborrhoeic dermatitis, Malassezia overgrowth
• Posterior blepharitis (meibomian gland dysfunction):
  • Altered meibomian gland secretion (thickened, inspissated meibum)
  • Associated with acne rosacea
• Demodex blepharitis: Demodex folliculorum or D. brevis mite infestation of lash follicles
• Mixed forms are very common

Pathophysiology

• Bacterial colonisation produces exotoxins and enzymes causing lid margin inflammation
• Altered meibomian secretion leads to tear film lipid layer instability
• Chronic inflammation damages lid margin architecture, meibomian gland orifices, and lash follicles
• Bacterial lipases break down meibum into free fatty acids, which are directly irritating to the ocular surface
• Results in secondary tear film instability and evaporative dry eye

Anterior Blepharitis

• Crusting at the base of eyelashes (collarettes in staphylococcal, greasy scales in seborrhoeic)
• Lid margin erythema and swelling
• Lash loss (madarosis) or misdirection (trichiasis) in chronic cases
• Itching and burning

Posterior Blepharitis (MGD)

• Lid margin irregularity and telangiectasia
• Capped or blocked meibomian gland orifices
• Frothy, foamy tear film
• Expression yields thickened, turbid, or toothpaste-like meibum

Associated Features

• Dry eye symptoms (gritty, burning, tearing)
• Recurrent styes (hordeolum) or chalazia
• Marginal keratitis (peripheral corneal infiltrates)
• Seborrhoeic dermatitis of face and scalp
• Acne rosacea

Red Flags

• Unilateral blepharitis (consider sebaceous gland carcinoma masquerading as chalazion)
• Madarosis (lash loss) with mass lesion (malignancy)
• Recurrent chalazion in same location (biopsy to exclude malignancy)
• Corneal involvement (keratitis, ulceration)

Bedside

• Slit lamp biomicroscopy: lid margin assessment, meibomian gland expression, corneal staining
• Visual acuity (should be normal unless corneal involvement)
• Classification: anterior vs posterior vs mixed

Bloods

• Not routinely required
• Consider screening for rosacea-associated conditions

Imaging

• Meibography if available (infrared imaging of gland structure)

Special Tests

• Epilated lash microscopy: Demodex mites if suspected
• Lid margin biopsy: if malignancy suspected (unilateral, recurrent chalazion, madarosis)
• Tear film assessment (Schirmer, TBUT) for coexisting dry eye

Non-pharmacological

• Lid hygiene is the cornerstone of management (life-long):
  1. Warm compresses: warm flannel or heated eye mask for 5-10 minutes BD (melts meibum)
  2. Lid massage: firm downward strokes on upper lid, upward on lower lid to express meibomian glands
  3. Lid scrubs: diluted baby shampoo or commercial lid wipes (Blephaclean, Systane lid wipes) along lash base
• Artificial tears for associated dry eye symptoms

Pharmacological

• Acute exacerbation: topical chloramphenicol 1% ointment to lid margins at bedtime for 2-4 weeks
• Posterior blepharitis/MGD refractory to lid hygiene:
  • Oral doxycycline 50-100mg OD for 6-12 weeks (anti-inflammatory properties)
  • Alternative: oral azithromycin 500mg OD for 3 days, repeat monthly for 3 months
• Demodex blepharitis: tea tree oil-based lid scrubs (Cliradex), or topical ivermectin
• Topical azithromycin 1% drops BD for 2 weeks then OD for 4 weeks (posterior blepharitis)
• Short course topical steroid (fluorometholone 0.1%) for acute marginal keratitis

Surgical

• Incision and curettage of chalazion if persistent (>6 weeks)
• Intraorbital steroid injection (triamcinolone) for chalazion (alternative to surgery)
• IPL (intense pulsed light) therapy for meibomian gland dysfunction
• LipiFlow thermal pulsation device

Referral Criteria

• Ophthalmology referral if: corneal involvement, recurrent chalazion (biopsy to exclude malignancy), refractory to lid hygiene and oral antibiotics, suspected malignancy
• Most blepharitis can be managed in primary care

• Chronic condition — complete cure is uncommon but symptoms can be well controlled with ongoing lid hygiene
• Most patients achieve satisfactory symptom control with consistent treatment
• Complications: chalazion (most common), stye, marginal keratitis, corneal scarring (rare), trichiasis, madarosis
• Meibomian gland dropout (atrophy) may occur with long-standing disease and is irreversible
• Associated dry eye disease may require independent treatment
• Recurrence is the norm if lid hygiene is discontinued

Comparison of Blepharitis Types

Chalazion vs Hordeolum (Stye)