Abstract
Ophthalmological problems make up approximately 2% of all consultations in primary care. The majority of problems are minor, encompassing ailments such as conjunctivitis, foreign bodies, blepharitis, subconjunctival hemorrhage, corneal abrasions, chalazions, and ectropions. However, more complex presentations, including ptosis and cataracts require accurate diagnosis, and may need referral to secondary care. General practitioners and members of the broader practice team, including advanced nurse practitioners and GP registrars, are likely to encounter such cases at least once every week. This article considers blepharitis and associated tear duct problems, providing a review of the simple and more complex presentations and their management. It will cover assessment in primary care, triggers, pathogenesis, epidemiology, typical presentations, clinical features, differential diagnoses, prevention, management strategies, and when referral to secondary care is necessary.
Clinical case scenario
Mr Smith, a 45-year-old gentleman, presents with his daughter after persisting eye irritation and redness in both eyes for the last 4 weeks, associated with crusting along the eye lids. He has not had any treatment. He has not previously had any issues with his eyes. He is concerned about the persistence of symptoms. On examination visual acuity is 20/20, pupils are equal and reactive to light and the eye lid margins appeared inflamed. Mild crusting and scaling is noted along the eye lid margins. He has a history of allergic rhinitis, hypertension and back pain. His current medication includes amlodipine, ramipril and fexofenadine. What is the most likely cause of this bilateral inflammation and crusting and how can this be managed?
Blepharitis
Blepharitis is an umbrella term for a number of conditions that cause inflammation of the eye lid margins. The condition can be a singular acute presentation, but is most often chronic dependent on the cause (Bernardes and Bonfioli, 2010).
Blepharitis can present affecting eye lashes only, termed anterior disease or anterior blepharititis. It can also affect the lubricating glands of the eye lids (meibomian glands) and is termed meibomian gland disease or posterior blepharitis.
Staphylococcal infections and seborrheic blepharitis can cause anterior blepharitis, with seborrheic blepharitis the more common cause. However, telling them apart clinically can be problematic (National Institute for Health and Care Excellence (NICE), 2019).
Anatomically, blepharitis is considered as anterior disease, where eye lashes are predominantly affected. In posterior blepharitis the meibomian glands are affected.
Pathogenesis
Blepharitis in the vast majority of cases is caused by a combination of factors including staphylococcal infection, seborrheic dermatitis and meibomian gland issues, or indeed a combination of all three. In patients with anterior blepharitis there is often overlap with posterior blepharitis (NICE, 2019).
When meibomian glands become blocked their secretions are reduced or actually become low quality contributing to dry eyes. Conditions such as seborrheic dermatitis and rosacea affect meibomian gland function, and it is important to diagnose these conditions (Lindsley et al., 2012). The multifactorial pathogenesis of blepharitis emphasises the need for comprehensive evaluation to address the wider aspects of blepharitis (Jackson, 2018).
Understanding the pathogenesis of blepharitis can be challenging, especially when demodex mites are implicated as the causative factor. These mites have been found to contribute to both anterior and posterior blepharitis by inducing an inflammatory response and obstructing follicles and glands (Liu et al., 2010).
Epidemiology
Blepharitis constitutes a significant proportion of ophthalmological presentations in primary care with a prevalence estimated at 37% in those aged 50 and older (Lindsley et al., 2012). Blepharitis is more prevalent in older age groups. The true prevalence of blepharitis is unknown, despite studies trying to estimate it. All forms of blepharitis are equal in their prevalence across both genders, apart from staphylococcal blepharitis which has a greater prevalence in women. Blepharitis typically presents in those aged in their forties and fifties.
Symptoms
Symptoms of blepharitis include a range of troubling sensations, including soreness or a gritty feeling in the eyes, associated with itching or a stinging burning sensation. A lot of patients with blepharitis complain of their eyelids sticking together, particularly upon waking in the morning. These symptoms can be accompanied by watery eyes, blurred vision and dryness in the eyes.
There may also be features of dandruff and facial rashes if blepharitis is triggered by seborrheic dermatitis. There may be facial flushing, redness and telangiectasia when the blepharitis is associated with rosacea. In rare presentations where a single eye is affected consider the possibility of a lid tumour (Turnbull and Mayfield, 2012).
Differential diagnosis
Interpreting the typical signs of blepharitis can pose a challenge, due to the overlap of signs and symptoms with other conditions. This highlights the importance of establishing a thorough understanding of this condition’s differential diagnosis. Symptoms such as itching, redness and a gritty sensation in the eyes can be indicative of eye disorders such as allergic conjunctivitis or dry eye syndrome. Signs of crusting along the eyelid margins with or without the presence of scales can be seen in ophthalmic conditions including seborrheic dermatitis and allergic reactions. Familiarity with the differential diagnosis of blepharitis is important for safe management of patients. Blepharitis has a wide range of potential causes, some of which are outlined in Box 1. Differential diagnosis of blepharitis and tear duct problems (dacryocystitis). Blepharitis differentials:
Seborrhoeic dermatitis Allergic conjunctivitis Contact dermatitis Dry eye syndrome Meibomian gland dysfunction Tear duct problem/dacryocystitis differentials:
Conjunctivitis Preseptal cellulitis Canaliculitis Chronic sinusitis Orbital sinusitis
Examination
Review the patient’s eye lids and their margins taking note of any inflammation, scale or flaking (Fig. 1), particularly of note with anterior blepharitis (particularly in seborrheic infections). Examine the surrounding skin for signs of telengiectasia which may be present if the underlying cause is rosacea. Examine for any eye lash loss, associated crusting or hard scales. Assess the eye lid margins for the presence of yellow droplets and perform a tear film examination if trained to do so. Chalazions are often seen and may be associated with scarring when inspecting the conjunctiva. Scarring and erosions across the cornea are seen in in more severe disease.
Inflammation of the eyelids.
Investigations
Diagnosis of blepharitis primarily relies on thorough examination rather than specific tests. In cases of severe or resistant symptoms, or when signs of other eye diseases are present, referral for a slit-lamp examination should be considered. Swabbing may be considered in severe or recurrent episodes, while biopsy becomes necessary if malignancy is suspected, particularly in patients with suspicious lesions or eyelash loss, often observed in older patients (NICE, 2019).
Onward referral
Referral is necessary in cases with associated cellulitis, malignancy or corneal involvement. Furthermore, if there is a reduction in visual acuity or moderate-to-severe pain, additional conditions beyond blepharitis may be involved and warrant specialist referral. If the diagnosis is uncertain or with concurrent disease then specialist referral is also appropriate.
Management
Blepharitis is managed in a multifaceted approach to alleviate specific symptoms, control any inflammation and reduce recurrent episodes. This involves daily eyelid hygiene exercises, such as lid scrubs to reduce crusting, eye lid massage to aid meibomian gland function and warm compresses. Lid hygiene is pivotal in management of uncomplicated episodes of blepharitis and this helps to cleanse the eye lid and maintain tear film production.
Antibiotics are prescribed in bacterial blepharitis alongside steroid drops or ointments to treat severe inflammation. Managing the underlying conditions such as meibomian gland dysfunction or ocular surface disease is important in terms of long-term management and disease recurrence.
When blepharitis presents with signs indicative of staphylococcal infection, prompt treatment is important, typically involving use of topical antibiotics for up to 6 weeks. However, where there is a poor response to initial treatment or when signs of associated conditions such as rosacea or meibomian gland dysfunction are present, oral antibiotics may be needed. Depending on the severity and persistence of symptoms, repeat courses of antibiotics may be warranted.
The regular use of artificial tears or lubricating drops is important, as dry eyes may promote inflammation and damage the health of the eyelid margins, worsening or giving rise to episodes of blepharitis. Artificial tears should be used during the day and thicker lubricants at night before bedtime. Artificial tears help alleviate symptoms of dryness and discomfort during the day, while thicker lubricants provide longer-lasting moisture and protection to the eyes overnight. This approach ensures continuous hydration and relief from symptoms throughout the day and night, contributing to overall comfort and well-being for individuals with blepharitis. Consider preservative-free preparations as the eyes are already inflamed and primed for a reaction to preservatives. Regular follow up is vital to monitor and adjust treatment as required or indeed refer to ophthalmology for refractory cases.
Complications of which to be aware
Untreated or inadequately managed blepharitis can lead to several complications affecting both the eyelids and adjacent structures. Chronic inflammation of the eyelid margins can result in functional impairment due to distortion of the eyelid architecture, often accompanied by thickening of the skin. Moreover, blepharitis can cause damage to the meibomian glands, leading to the formation of large, painful cysts that may become infected, visually unappealing, and contribute to astigmatism. Additionally, blepharitis can cause complications beyond the eyelids, including corneal ulceration or keratitis, which, if left untreated, can progress to vision loss and even blindness. It is important to use fluorescein stain to detect marginal keratitis, which occurs most commonly in blepharitis. Effective management of blepharitis is crucial in preventing these complications and preserving both ocular health and visual acuity.
Blepharitis is a chronic condition marked by cycles of remission, relapse, and exacerbation. With patient education and commitment to lid hygiene, complications can be effectively managed and the frequency of exacerbations reduced and minimised. Stressing the importance of consistent preventive measures during follow-up appointments is vital for long-term management. Prompt treatment of eye-related complications can help prevent permanent damage to eyesight resulting from inadequate management.
Case discussion
Having considered the patient’s assessment, epidemiology and differential diagnosis, we will now revisit the case scenario which initially presented with persistent eye irritation in the absence of any discharge. The examination revealed inflammation of the eyelid margins with crusting and normal visual acuity. Based on these findings and the patient’s history, anterior blepharitis is strongly suspected to be the diagnosis. To confirm the diagnosis, consider swabbing the eyes to detect pathogenic micro-organisms and tear film analysis, which typically reflects reduced tear film production in blepharitis. Swabbing the eyes is indicated when treatment is less effective or in severe cases. Strategies include initiating prompt eyelid hygiene exercises, possibly steroid eye drops for management of inflammation and follow-up appointments to monitor progress. Failure to improve should prompt referral to ophthalmology.
Key points
Blepharitis is a common condition characterised by inflammation of the eyelids, specifically the eyelid margins
Symptoms include redness, swelling, itching, burning sensation, crusting of the eyelids, and sensitivity to light
Blepharitis can be caused by bacteria, blockage of the eyelid glands, or skin conditions such as seborrheic dermatitis or rosacea, often underdiagnosed
Treatment typically involves eyelid hygiene practices such as warm compresses, lid scrubs, and eyelid massage, along with antibiotics or steroid eye drops in severe cases
Chronic blepharitis requires ongoing management to control symptoms and prevent flare-ups
