Blepharitis causes and management

Case Scenario

Parag is a 49-year-old call centre worker who comes into the pharmacy with irritated eyes. He says he often has mildly red and itchy eyes. He thinks his eyes are reacting to excessive screen

time. On further questioning, Parag mentions that there are often crusty flakes at the base of his eyelashes when he wakes in the morning. On inspection, it appears his eyelids are mildly inflamed. Further inspection of the affected areas and careful questioning of Parag’s history rules out any symptoms that may require referral. Parag reports that he occasionally wears reading glasses. He is in good health with no other medical conditions.

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Introduction

Blepharitis, or inflammation of the eyelids, is a common, typically bilateral, non-sight-threatening eye condition that can affect adults and children. Although common, the diagnosis and treatment of blepharitis can be complex due to the multitude of potential causes, and that it can also present as a symptom of another condition.

Blepharitis can be broadly categorised by the location and duration of the symptoms. Firstly, the location can be anterior (the outside front of the eyelid where the eyelashes attach), posterior (the inner eyelid; may include the meibomian gland) or a combination of anterior and posterior. Secondly, the duration may be either acute (treatment usually effective) or, more commonly, chronic.

Common symptoms of blepharitis include reddening, watery eyes, itch, burning, flakiness, crustiness, grittiness and dry eyes.¹ There are numerous factors that cause blepharitis.

Targeting patient-specific factors can ensure the most appropriate management is provided to reduce the burden of the condition.

What are the symptoms?

The symptoms of blepharitis can vary between patients but are relatively consistent across the subtypes. They are often worse in the morning on waking, and typically affect both eyes.² There is also significant overlap with other conditions, such as dry eye, seborrheic dermatitis (dandruff), rosacea and allergies.³

A large US-based study (n = 5,019) examined blepharitis symptoms in adults older than 18 years.⁴ Of the respondents, 79% reported that they had experienced at least one symptom in the previous 12 months.⁴ The study found that symptoms are most often reported by younger people, and there is minimal difference in symptoms between genders.⁴

What questions would you ask and why?

Pharmacists who suspect blepharitis in a patient should ask the patient to describe their symptoms and visually inspect the eyes to help make an accurate diagnosis (see ‘How is it diagnosed?’). 

Careful questioning and understanding of the patient’s history of symptoms will also help ascertain the cause and guide management of the condition. Referral to a general practitioner may be required, especially if red-flag symptoms are present (see ‘When is referral required?’).

What are the causes, risk factors and complications?

Seborrheic blepharitis

Seborrheic blepharitis is an anterior blepharitis and is the most common form of the condition. It is caused by seborrheic dermatitis (dandruff) of the eyelid.³ It causes less redness, inflammation and telangiectasia (spider veins) than staphylococcal blepharitis, but with more oily or greasy scaling.^1,3 Individuals with seborrheic dermatitis have an increased risk of developing seborrheic blepharitis.^1,3

Staphylococcal blepharitis

Staphylococcus aureus is found on the ocular surface and may colonise the base of the eyelashes, leading to an anterior blepharitis characterised by marked redness and inflammation of the eyelids.¹ Symptoms are often more severe and may include stickiness, pustules, ulceration and telangiectasia.¹ In more severe cases, trichiasis (misdirection of the eyelashes), poliosis (a depigmentation of the eyelashes), madarosis (a loss of the eyelashes) and corneal scarring may occur.^1,3

Meibomian gland dysfunction

(MGD) blepharitis The meibomian glands are oil (meibum) secreting glands found in the margins of the eyelid. The secreted oil functions to coat the ocular surface, reducing tear evaporation. MGD may be caused by a physical blockage of the gland ducts, and/or a reduction in the quality of the meibomian secretions.¹ Symptoms of MGD, a posterior blepharitis, include eye irritation and inflammation.¹

Other causes of blepharitis

Other causes that may resemble or contribute to symptoms of blepharitis include¹:

• Rosacea, an inflammatory condition characterised by face redness that may also be ocular in nature. Ocular rosacea causes inflammation of the eyelid and may resemble symptoms of blepharitis. It is classified as a posterior blepharitis.
• Demodex mite infection caused by one of two Demodex mites that can be found at either the base of the eyelashes (anterior blepharitis) or within the meibomian glands (posterior blepharitis).⁵ Demodex infections typically present with cylindrical dandruff.⁶
• Contact allergies to make-up, contact lenses or solutions, or other topical facial products.³ Allergic forms of blepharitis are typically classified as posterior.
• Conjunctivitis can cause inflammation similar to blepharitis.¹
• Long-term contact lens use.⁶
• Medicines can aggravate the symptoms of blepharitis, including^1,7,8:
  • isotretinoin
  • diuretics
  • estrogens
  • tricyclic antidepressants
  • topical vasoconstrictors
  • corticosteroids
  • treatments for glaucoma
  • androgen antagonists.

When is referral required?

Blepharitis is typically not a sight- limiting condition. There are however instances when the pharmacist should refer the patient for review by a general practitioner or optometrist. These include when symptoms are not responding to appropriate treatment, when there is suspected Demodex infestation, or when prescription treatments are required.

Red-flag symptoms that can indicate a more severe condition and require referral to a general practitioner, optometrist or appropriate hospital emergency department for immediate sight-saving medical attention include^6,9,10,11:

• Sudden onset of symptoms linked to a particular event (e.g. eye trauma).
• Dry mouth along with dry eye.
• Severe foreign body sensation, visible foreign body or penetration injury.
• Corneal opacity.
• Severe or sudden pain in one or both eyes.
• Severe photophobia.
• Marked redness of the affected area.
• Loss of vision (decreased visual acuity).

How is it diagnosed?

Diagnosis of blepharitis is made after assessing the patient’s symptoms and taking an appropriate history in order to ascertain the likely cause. Due to its chronic and recurrent nature, patients may have previously received a diagnosis and are seeking treatment for a flare-up. Pharmacists should consider symptoms and conditions that are similar to or unlike blepharitis when assessing the patient. A differential diagnosis considers other possible causes of the patient’s symptoms to ensure the diagnosis is accurate. See Table 1.

Table 1 – Differential diagnosis of blepharitis

What is the management approach?

The goals of blepharitis treatment are to relieve symptoms and prevent recurrence where possible.¹² There is no evidence that currently available treatments can cure blepharitis.¹ There is evidence supporting the use of lid hygiene techniques and topical antibiotics to improve symptoms.¹

Non-pharmacological treatments

Lid hygiene is recommended as first-line management, irrespective of the type or cause of blepharitis.^1,6,12,14 Lid hygiene cleans away any crusty deposits and bacteria from the eyelid margin.^1,6 There are many lid hygiene techniques, and there is little evidence to support one method over another.^1,6

Patients should be encouraged to perform twice daily lid hygiene when symptomatic, and daily when asymptomatic.^1,2,6,12,14

Lid hygiene steps can include:

• Apply a warm compress (e.g. wash cloth soaked in warm water, approximately 40 °C) twice daily for 5–10 minutes. Warm compresses may melt secretions blocking the meibomian glands and may also aid in softening crusty deposits.^1,6,12
• With clean hands, massage the affected eyelid area(s) by gently pressing the eyelid against the eyeball. This may help express blocked meibomian glands.¹
• Gently scrub the eyelid area with a wet washcloth, cotton bud, gauze, or similar, twice daily.^1,6,12
• A diluted soap solution (e.g. 1 part baby shampoo to 10 parts cool boiled water), sodium bicarbonate solution (add 1/4 teaspoon of sodium bicarbonate to 250 mL of cool boiled water), saline solution, or a commercially available lid cleanser or wipe may be used.^1,6,12,14,16

Pharmacological treatment

Seborrheic and staphylococcal blepharitis may not respond to lid hygiene techniques alone. Where lid hygiene techniques do not improve symptoms, and symptoms of dry eye are also present, consider adding lubricating eye product.^2,17 Re-wetting of the eye may aid in preventing flare-ups caused by chronic dry eye; ointments are preferred as they remain on the lid for longer.¹⁸

The patient may also be encouraged to trial:

• Increasing intake of omega-3 and omega-6 fatty acids through diet or supplements. This may improve the inflammatory and dry eye symptoms of blepharitis.^1,17
• 50% tea-tree oil solution may be used for confirmed Demodex blepharitis.Undiluted tea tree oil may be toxic to the ocular surface, and as such the treatment should be recommended only by experienced practitioners.^5,17

If lid hygiene and non-prescription treatments do not adequately improve symptoms, the patient should be referred to their GP or optometrist for further investigation. The patient may be prescribed medication such as:

• Chloramphenicol 1% eye ointment topically. Apply to the eyelid margin, twice daily for 1–2 weeks.¹⁴ It is used to reduce bacterial load and for inflammatory properties.^1,17
• Adult (non-pregnant, non- breastfeeding): doxycycline 100 mg daily until clinical improvement (approximately 2–4 weeks); reduce to 50 mg daily for a total treatment duration of 8 weeks minimum.^14,17 Tetracyclines are particularly useful for rosacea-associated blepharitis.^1,12,17 Adult (pregnant, breast-feeding): erythromycin (base) 500 mg daily for 8 weeks minimum. Reduce to 250 mg daily if poorly tolerated.¹⁴
• A short course of a topical corticosteroid may be indicated if inflammation or pain is severe.¹⁵

Ivermectin may be prescribed for refractory Demodex blepharitis.^12,19 Only the topical formulations are registered for this use in Australia.

Ongoing trials are investigating the efficacy of topical ciclosporin and topical tacrolimus in blepharitis, though neither medicine is routinely used or licensed for this indication in Australia.^17,20,21 Table 2 summarises blepharitis management.

Table 2 – Summary of blepharitis management by stage

Adverse effects

Common adverse effects of blepharitis treatments include^9,12:

• Lid hygiene
  • lid scalding, skin irritation, sensitivity, or dermatoses from scrub solution

• Topical chloramphenicol
  • stinging or burning, hypersensitivity (rare)

• Oral antibiotics
  • gastrointestinal effects, tooth discolouration, photosensitivity

• Topical corticosteroids
  • raised intra-ocular pressure, increased local infection risk.

What are the preventive measures?

Preventive management of blepharitis is lid hygiene. Due to the chronic and recurring nature of blepharitis, patients should be strongly encouraged to persist with lid hygiene even when asymptomatic. Where there are specific triggers that worsen symptoms, such as eye make-up or contact lenses and solutions that can irritate the skin or eye, patients should be encouraged to avoid these where possible.

Management of comorbidities (rosacea, seborrheic dermatitis) that may promote or worsen blepharitis should also be encouraged.

Knowledge to practice

Understanding the breadth of symptoms and causes of blepharitis will ensure pharmacists can competently support and educate patients to better manage the condition.

Pharmacists should screen patients who present with symptoms of blepharitis for red-flag ocular symptoms that may require referral to a GP or optometrist for further investigation, or an appropriate hospital emergency department when sudden onset central vision loss or a sight-limiting condition is suspected.²²

Pharmacists can manage patients with blepharitis by diagnosing the condition and recommending referral when appropriate, recommending treatment, and providing education about the condition.

Pharmacists should ensure patients understand that adherence to lid hygiene is fundamental in the management and prevention of blepharitis flare-ups.

Patients should avoid eye make-up and contact lens use if possible when on active treatment.^1,22 A lubricating eye product may be useful when the eyes are dry.²²

Conclusion

Blepharitis is a common, often chronic eye complaint that may resemble or be caused by other conditions. Typical symptoms include redness, inflammation, itch, watering, and dandruff-like crusts on the eyelashes (particularly at the base). The main causes include seborrheic dermatitis, Staphylococcus infection and meibomian gland dysfunction. Adherence to ongoing lid hygiene is essential, regardless of the cause or symptoms of blepharitis. Treatment with antibiotics and/or topical corticosteroids may be required in some cases. Pharmacists are frequently the first point of contact for patients with blepharitis-like symptoms due to their accessibility and availability, and it is essential that pharmacists can competently assess, manage, educate and refer patients where appropriate.

Further information

• Lid hygiene patient information with detailed diagrams from Moorfields Eye Hospital
• Blepharitis practice guidelines from the American Academy of Ophthalmology
• Detailed management and treatment of MGD guidance from the International Workshop of MGD

Key points

• Blepharitis, or inflammation of the eyelids, is a chronic recurring condition with no cure.
• Lid hygiene is the mainstay of blepharitis prevention and management.
• Pharmacists are well placed to assess and refer patients who present with red-flag symptoms that may require immediate medical review.

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References

1. Lindsley K, Matsumura S, Hatef E, et al. Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews 2012, Issue 5.
2. American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern®Guidelines. Blepharitis. San Francisco, CA: American Academy of Ophthalmology; 2008. At: www.aao.org/ppp
   
3. Michail M. Episode 2–Blepharitis. Australian Pharmacist 2011 Feb;30(2):120–3.
4. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf 2009;7(2):S1–4.
5. Savla K, Le JT, Pucker AD. Tea tree oil for Demodex blepharitis. Cochrane Database of Systematic Reviews 2020, Issue 6.
6. The College of Optometrists. Blepharitis (lid margin disease). 2018. At: www.college-optometrists.org/guidance/clinical-management-guidelines/blepharitis-lid-margin-disease.htm
7. Moy A, McNamara NA, Lin MC. Effects of isotretinoin on meibomian glands. Optom Vis Sci 2015;92(9):925–30.
8. Braily A, ed. Responding to Minor Ailments. Glasgow: NHS Education Scotland; 2009.
9. Numan H. Conjunctivitis. Australian Pharmacist 2021;40(1):44–52.
10. The Pharmaceutical Journal. Pharmacy technician’s guide – dry eye disease: pathophysiology and risk factors. 2017. At: http://pharmaceutical-journal.com/article/ld/pharmacy-technicians-guide-dry-eye-disease-pathophysiology-and-risk-factors
11. Kilduff C, Lois C. Red eyes and red-flags: improving ophthalmic assessment and referral in primary car. BMJ Open Qual2016;5:u211608.
12. Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2021.
13. Nanda L, Sanjana SM, Srivastava VK, et al. Meibomian gland carcinoma of the eyelid: a rare case report. Int J Sci Study 2015;3(3):140–2.
14. Blepharitis In: eTG complete. Melbourne: Therapeutic Guidelines; 2019.
15. Wong K. Blepharitis. 2009. At: https://dermnetnz.org/topics/blepharitis
16. Moorfields Eye Hospital. GP handbook: common eye condition management. London: NHS Foundation Trust; 2017.
17. Geerling G, Tauber J, Baudouin C, et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Investig Ophthalmol Vis Sci 2011;52(4):2050–64.
18. Patterson C, ed. AMH Aged Care Companion. Adelaide: Australian Medicines Handbook; 2021.
19. Holzchuh FG, Hida RY, Moscovici BK, et al. Clinical treatment of ocular Demodex folliculorum by systemic ivermectin. Am J Ophthalmol 2011;151(6):1030–4.
20. Gaynes BI, Fiscella R. Topical nonsteroidal anti-inflammatory drugs for ophthalmic use: a safety review. Drug Saf 2002;25:233–50.
21. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea 2006;25:171–5.
22. The Royal Victorian Eye and Ear Hospital. Primary care management guidelines – blepharitis. Melbourne: The Royal Victorian Eye and Ear Hospital; 2015.

KATE PETRIE BPharm MBA MSc (ClinPharm) is a Clinical Pharmacist who has worked in public hospitals in both Australia and the UK. She is a Teaching Associate and PhD candidate at Monash University.