Summary

Blepharitis is a common, chronic inflammatory condition of the eyelid margins. It is a leading cause of ocular surface disease and dry eye symptoms. It is classically divided into Anterior Blepharitis (affecting the eyelash base – typically Staphylococcal or Seborrhoeic) and Posterior Blepharitis (affecting the meibomian glands – Meibomian Gland Dysfunction (MGD)). In practice, most patients have a combination of both. Symptoms include gritty, burning, irritated eyes with crusting on the lashes. While rarely sight-threatening, blepharitis is chronic and often frustrating for patients, requiring long-term management with lid hygiene.

Key Facts

• Prevalence: Extremely common. Up to 50% of patients seen in eye clinics have some degree of blepharitis.
• Classification: Anterior (Staphylococcal/Seborrhoeic) vs. Posterior (MGD).
• Associations: Rosacea (strongly linked to MGD), Seborrhoeic Dermatitis, Demodex mites.
• Complications: Chalazion, Stye (Hordeolum), Dry Eye, Corneal Ulceration (rare).
• Management: Lid hygiene is the cornerstone. Warm compresses, Lid massage, Lid scrubs.
• Chronic Course: This is a management condition, not a cure. Patient education is key.

Clinical Pearls

"Anterior = Lashes, Posterior = Glands": Anterior blepharitis causes collarettes (dandruff-like flakes) around lash bases. Posterior (MGD) causes capped/inspissated meibomian gland orifices on the lid margin.

Check for Rosacea: MGD and Rosacea go hand-in-hand. Ask about facial flushing, rhinophyma, telangiectasia. Consider dermatology referral.

Unilateral Blepharitis is a Red Flag: Blepharitis is almost always bilateral. A unilateral presentation that doesn't respond to treatment should raise suspicion for Sebaceous Gland Carcinoma masquerading as blepharitis. Biopsy.

The Demodex Mite: Demodex folliculorum and D. brevis are mites that live in hair follicles and meibomian glands. Cylindrical dandruff ("collarettes" clasping the lash base) is suggestive of Demodex blepharitis. Treat with Tea Tree Oil lid wipes.

Why This Matters Clinically

Blepharitis accounts for a significant proportion of eye complaints in primary and secondary care. While not an emergency, it causes substantial morbidity. Understanding the difference between anterior and posterior types, and the importance of long-term lid hygiene, allows effective management and patient counselling.

Slit Lamp Examination

The Gold Standard for assessing blepharitis.

1. Lid Margins: Inspect for erythema, telangiectasia, crusting, collarettes, ulceration.
2. Lash Bases: Collarettes? Loss of lashes (Madarosis)? Misdirection (Trichiasis)?
3. Meibomian Gland Orifices: Capped? Pouting? Express glands (apply gentle pressure on lid) – what comes out? (Clear liquid = normal. Thick/toothpaste = MGD).
4. Conjunctiva: Injection? Papillae?
5. Cornea (with Fluorescein): Superficial punctate keratopathy (SPK)? Ulceration?

Differential Diagnosis

Red Flag: Sebaceous Gland Carcinoma (Masquerader)

The missed diagnosis.

• What is it? A rare but aggressive malignancy of the meibomian glands (or glands of Zeis).
• Why dangerous? It mimics chronic blepharitis or recurrent chalazion. Delays diagnosis.
• Clinical Clues:
  • Unilateral presentation.
  • Resistant to treatment (doesn't respond to hygiene).
  • Loss of lash architecture (Madarosis).
  • Pagetoid spread (looks like diffuse conjunctivitis).
  • Recurrent "chalazion" in the same spot.
• Action: Biopsy the lid margin. Full-thickness biopsy may be needed.
• Prognosis: Can metastasize. Early diagnosis is critical.

Drill Down: When to Perform a Lid Biopsy

• Chronic Condition: Blepharitis is rarely cured. It is managed, not treated to resolution.
• Fluctuating Course: Flares and remissions are typical.
• Long-term Outcome: With good lid hygiene, most patients achieve good symptom control.
• Patient Frustration: Common. Emphasise that this is a "maintenance" condition like brushing teeth.

Key Guidelines

Evidence for Interventions

Drill Down: Omega-3 Fatty Acid Supplementation

Controversial but widely used.

• Rationale: Omega-3 (EPA/DHA from fish oil) has anti-inflammatory properties and may improve meibum quality.
• Evidence: Mixed. DREAM Study (2018, NEJM) found no benefit of Omega-3 over placebo for dry eye. However, subgroup analyses and other studies suggest benefit in MGD specifically.
• Practical Advice: Reasonable to recommend in MGD patients, especially if low dietary intake. Dose: ~2g EPA+DHA daily. Minimal harm.
• Alternatives: Flaxseed oil (plant-based ALA, less effective conversion to EPA/DHA).

Treatment Ladder: Blepharitis Severity

Scenario 1:

• Stem: 55-year-old woman complains of gritty, burning eyes and crusted lashes in the morning. Lid margins are red with collarettes at lash bases. What is the diagnosis and management?
• Answer: Anterior Blepharitis (likely Staphylococcal). Management: Lid hygiene (Warm compress, Massage, Lid scrubs). Topical Chloramphenicol ointment to lid margins if needed. Lubricants for dry eye symptoms.

Scenario 2:

• Stem: A patient with Rosacea has chronic dry eye. Meibomian gland expression reveals thick, toothpaste-like secretions. What is the management?
• Answer: Posterior Blepharitis (MGD) associated with Rosacea. Lid hygiene. Lubricants (especially lipid-based drops). Oral Doxycycline 100mg OD for 6-12 weeks. Consider dermatology referral for Rosacea management.

Scenario 3:

• Stem: What are the "red flags" in blepharitis that should prompt further investigation?
• Answer: 1) Unilateral blepharitis unresponsive to treatment (Exclude Sebaceous Gland Carcinoma). 2) Madarosis (Lash loss) – Biopsy to exclude malignancy. 3) Corneal involvement (Ulceration) – Urgent Ophthalmology.

Scenario 4:

• Stem: Cylindrical dandruff clasping the base of eyelashes is seen. What is the likely cause and treatment?
• Answer: Demodex Blepharitis (Demodex folliculorum). Treatment: Tea Tree Oil lid wipes daily. Oral Ivermectin if severe.

Scenario 5:

• Stem: How should you counsel a patient newly diagnosed with blepharitis?
• Answer: "This is a chronic condition. There is no quick fix or permanent cure. The mainstay of treatment is a daily lid hygiene routine – think of it like brushing your teeth for your eyes. Warm compress, massage your lids, clean the lash line. Done regularly, this will control your symptoms."

What is Blepharitis?

Blepharitis is inflammation of the eyelids. It is very common and causes sore, red, gritty eyes that may feel dry. You may notice crusty material on your eyelashes, especially in the morning.

Why does it happen?

It is usually caused by problems with tiny oil glands in your eyelids (Meibomian Gland Dysfunction) or by bacteria around your lashes. It often goes along with skin conditions like Rosacea.

Is there a cure?

There is no quick cure, but it can be controlled. The key is a daily lid hygiene routine, similar to brushing your teeth:

1. Warm Compress: Apply a warm, damp cloth to your closed eyes for 5-10 minutes.
2. Massage: Gently massage your eyelids to help release blocked oils.
3. Clean: Wipe along your lash line with a lid wipe or diluted baby shampoo on a cotton bud.

What else can help?

• Lubricating eye drops (artificial tears).
• Sometimes antibiotic eye ointment or tablets.
• Avoid rubbing your eyes or wearing eye makeup during flares.

When should I see a doctor?

• If your symptoms are not improving with lid hygiene.
• If you have pain, light sensitivity, or vision problems.
• If you are losing eyelashes or only one eye is affected.

Key Counselling Points (For Clinicians)

1. Set Expectations: "This is a lifelong condition like eczema. We manage it, not cure it."
2. Emphasise Routine: "Daily lid hygiene is the most important treatment – even when your eyes feel good."
3. Warm Compress Technique: Ensure patient understands sustained warmth (5-10 mins) is needed, not just a quick dab.
4. Reinforce Lubricants: "Drops are like moisturiser for your eyes. Use them regularly, especially preservative-free if using frequently."
5. Address Frustration: "Many people find this condition frustrating. Stick with the routine and symptoms improve."
6. Makeup Advice: "Avoid heavy eye makeup during flares. Remove all makeup thoroughly. Replace old mascara."
7. Contact Lens Advice: "If you wear contact lenses, MGD can make them uncomfortable. Speak to your optician about lens type and drops."

Historical Context & Etymology

Origin of the terminology.

• "Blepharitis": From Greek blepharon (eyelid) + -itis (inflammation).
• "Meibomian Glands": Named after Heinrich Meibom (1638-1700), German physician and anatomist who first described these glands in 1666.
• Recognition of MGD: Only formally defined by the TFOS International Workshop in 2011, despite being described for centuries.

Differential by Location

Quick Reference:

Common Patient Questions