Blepharitis is a common chronic bilateral inflammatory condition of the lid margins. Anterior blepharitis involves the lid skin, eyelashes, and associated glands. It may be ulcerative because of infection by staphylococci, or seborrheic in association with seborrhea of the scalp, brows, and ears. Posterior blepharitis results from inflammation of the meibomian glands. There may be bacterial infection, particularly with staphylococci, or primary glandular dysfunction, in which there is a strong association with acne rosacea.
Symptoms are irritation, burning, and itching. In anterior blepharitis, the eyes are “red-rimmed” and scales or collerettes can be seen clinging to the lashes (eFigure 7–9A). In posterior blepharitis, the lid margins are hyperemic with telangiectasias, and the meibomian glands and their orifices are inflamed (eFigure 7–9B). The lid margin is frequently rolled inward to produce a mild entropion, and the tear film may be frothy or abnormally greasy.
Blepharitis. A: Severe anterior blepharitis. B: Posterior blepharitis with inspissated meibomian glands. (From M Reza Vagefi. Reproduced, with permission, from Riordan-Eva P, Augsburger JJ. Vaughan & Asbury’s General Ophthalmology, 19th ed. McGraw-Hill, 2018.)
Blepharitis is a common cause of recurrent conjunctivitis. Both anterior and, more particularly, posterior blepharitis may be complicated by hordeola or chalazia; abnormal lid or lash positions, producing trichiasis; epithelial keratitis of the lower third of the cornea; marginal corneal infiltrates; and inferior corneal vascularization and thinning.
Anterior blepharitis is usually controlled by eyelid hygiene. Warm compresses help soften the scales and warm the meibomian gland secretions. Eyelid cleansing can be achieved by gentle eyelid massage and lid scrubs with baby shampoo or 0.01% hypochlorous acid. In acute exacerbations, an antibiotic eye ointment, such as bacitracin or erythromycin, is applied daily to the lid margins.
In mild posterior blepharitis, regular meibomian gland expression and warm compresses may be sufficient to control symptoms. Inflammation of the conjunctiva and cornea indicates a need for more active treatment, including long-term low-dose oral antibiotic therapy, usually with tetracycline (250 mg twice daily for 2–4 weeks), doxycycline (100 mg daily for 2–4 weeks), minocycline (50–100 mg daily for 2–4 weeks) erythromycin (250 mg three times daily for 2–4 weeks), or azithromycin (500 mg daily for 3 days in three cycles with 7-day intervals). Short-term (5–7 days) topical corticosteroids, eg, prednisolone, 0.125% twice daily, may also be indicated. Topical therapy with antibiotics, such as ciprofloxacin 0.3% ophthalmic solution twice daily, may be helpful but should be restricted to short courses of 5–7 days.
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