Most patients with meibomian gland dysfunction or seborrheic blepharitis have increased tear evaporation and secondary keratoconjunctivitis sicca , also known as dry eye. Symptoms common to all forms of blepharitis include itching and burning of the eyelid margins and conjunctival irritation with lacrimation, photosensitivity, and foreign body sensation. In acute ulcerative blepharitis, small pustules may develop in eyelash follicles and eventually break down to form shallow marginal ulcers.
Tenacious adherent crusts leave a bleeding surface when removed. During sleep, eyelids can become glued together by dried secretions. Recurrent ulcerative blepharitis can cause eyelid scars and loss or misdirection trichiasis of eyelashes. In acute nonulcerative blepharitis, eyelid margins become edematous and erythematous; eyelashes may become crusted with dried serous fluid. In meibomian gland dysfunction, examination reveals dilated, inspissated gland orifices that, when pressed, exude a waxy, thick, yellowish secretion. In seborrheic blepharitis, greasy, easily removable scales develop on eyelid margins.
Most patients with seborrheic blepharitis and meibomian gland dysfunction have symptoms of keratoconjunctivitis sicca, such as foreign body sensation, grittiness, eye strain and fatigue, and blurring with prolonged visual effort. Diagnosis is usually by slit-lamp examination. Chronic blepharitis that does not respond to treatment may require biopsy to exclude eyelid tumors that can simulate the condition.
Acute blepharitis most often responds to treatment but may recur, develop into chronic blepharitis, or both. Chronic blepharitis is indolent, recurrent, and resistant to treatment. Exacerbations are inconvenient, uncomfortable, and cosmetically unappealing but do not usually result in corneal scarring or vision loss.
Antimicrobials for acute ulcerative blepharitis; warm compresses and sometimes topical corticosteroids for acute nonulcerative blepharitis. For chronic blepharitis, treatment of keratoconjunctivitis sicca, warm compresses, cleansing of eyelids, and sometimes topical or systemic antibiotics as clinically indicated. Acute viral ulcerative blepharitis is treated with systemic antivirals eg, for herpes simplex, acyclovir mg orally 3 times a day for 7 days; for varicella zoster, famciclovir mg orally three times a day or valacyclovir 1 g orally 3 times a day for 7 days.
Treatment of acute nonulcerative blepharitis begins with avoiding the offending action eg, rubbing or substance eg, new eye drops.
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Warm compresses over the closed eyelid may relieve symptoms and speed resolution. The initial treatment for both meibomian gland dysfunction and seborrheic blepharitis is directed toward the secondary keratoconjunctivitis sicca. While the etiology of blepharitis is complex and not fully understood, bacteria and inflammation are believed to contribute to the pathology. Long-term management of symptoms may include daily eyelid cleansing routines and the use of therapeutic agents that reduce infection and inflammation.
Blepharitis is one of the most common ocular disorders encountered in clinical practice. A recent cross-sectional study in Spain based on a randomly selected sample population reported rates of asymptomatic and symptomatic meibomian gland dysfunction of Blepharitis can affect all age and ethnic groups.
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Its role has not been firmly established since Demodex can be found with nearly the same prevalence in asymptomatic patients. Nonetheless, patients with recalcitrant blepharitis have responded to therapy directed at eradicating the Demodex mites. Staphylococcal blepharitis is believed to be associated with staphylococcal bacteria on the ocular surface. Seborrheic blepharitis is characterized by less inflammation than staphylococcal blepharitis but with more oily or greasy scaling.
Some patients with seborrheic blepharitis also exhibit characteristics of MGD. Meibomian gland dysfunction is characterized by functional abnormalities of the meibomian glands and altered secretion of meibum, which plays an important role in slowing the evaporation of tear film and smoothing the tear film to provide an even optical surface. The diagnosis of blepharitis is usually based on a typical patient history and characteristic slit-lamp biomicroscopic findings, described below. Ancillary testing, such as conjunctival cultures, can be helpful.
Symptoms of chronic blepharitis may include redness, burning sensation, irritation, tearing, eyelid crusting and sticking, and visual problems such as photophobia and blurred vision. Symptoms are typically worse in the mornings and a patient may have several exacerbations and remissions. While the clinical features of the blepharitis categories can overlap, certain signs and symptoms are more commonly associated with particular subtypes.
Staphylococcal blepharitis is characterized on examination by erythema and edema of the eyelid margin. In severe and long-standing cases, eyelid ulceration and corneal scarring may occur. Seborrheic blepharitis is differentiated by less erythema, edema, and telangiectasia of the lid margins as compared to staphylococcal blepharitis, but an increased amount of oily scale and greasy crusting on the lashes. The meibomian glands may appear capped with oil, be dilated, or be visibly obstructed.
The secretions of the glands are usually turbid and thicker than normal. Telangiectasias and lid scarring may also be present in this area. Chalazia may be a cause or consequence of MGD. In all forms of blepharitis, examination of the tear film may show instability and rapid evaporation. There is general agreement that a TBUT shorter than 10 seconds reflects tear film instability. There are no specific clinical diagnostic tests for blepharitis, however, cultures of the eyelid margins may be indicated for patients who have recurrent anterior blepharitis with severe inflammation, as well as for patients who are not responding to therapy.
Measurement of tear osmolarity may be useful in diagnosing concurrent dry eye syndrome. Microscopic evaluation of epilated eyelashes may reveal Demodex mites, which have been implicated in some cases of chronic blepharoconjunctivitis. The specimen is prepared for microscopy by placing the explanted eyelashes on a glass slide, adding a drop of fluorescein, and securing the specimen beneath a cover slip.
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Eyelid Inflammation (Blepharitis)
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