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Ophthalmology – Blepharitis
Blepharitis is a chronic, recurrent inflammation of the eyelid margin and is one of the most common conditions encountered in ophthalmology practice. It is broadly divided into two types: anterior blepharitis (also called seborrheic blepharitis), which affects the front of the eyelid at the base of the eyelashes, and posterior blepharitis (meibomian gland dysfunction), which involves the meibomian glands located behind the eyelashes. The condition is common, affecting up to nearly half of patients seen in eye clinics, and although more frequently noted in individuals of Northern European descent, it occurs across all populations.
The underlying mechanisms differ between the two types. In anterior blepharitis, excessive scaling of the skin at the eyelid margin, often associated with seborrheic dermatitis and colonization by organisms such as Malassezia, leads to inflammation. In posterior blepharitis, abnormal composition and secretion of lipids from the meibomian glands result in gland obstruction and inflammation. Both conditions are often influenced by genetic predisposition and may run in families.
Patients typically present with symptoms of eyelid irritation, including itching, burning, redness, and fluctuating discomfort throughout the day. Many also experience symptoms of evaporative dry eye, such as foreign body sensation and blurred vision. Those with anterior blepharitis often notice flaky debris at the base of the eyelashes, while patients with meibomian gland dysfunction may describe thick, waxy secretions along the eyelid margin or recurrent eyelid lumps such as chalazia.
On examination, anterior blepharitis is characterized by crusting and scaling at the lash line, redness of the anterior lid margin, and debris in the tear film, often accompanied by punctate keratitis. Posterior blepharitis shows plugged meibomian gland orifices with thick, yellowish secretions, diffuse lid margin redness, and abnormal tear film lipid layer. Associated findings may include telangiectatic vessels along the lid margin, chalazia, and signs of acne rosacea.
Diagnosis is clinical and based on history and slit-lamp examination. Laboratory testing is rarely required, although cultures may occasionally be performed in resistant cases. Histopathologic findings include epidermal changes and inflammatory infiltrates in anterior blepharitis, and gland obstruction with inflammatory changes in meibomian gland dysfunction.
Management focuses on long-term control rather than cure. For anterior blepharitis, the mainstay of treatment is eyelid hygiene, particularly regular eyelash scrubs using a dilute baby shampoo solution. If needed, topical antibiotic ointments may be added. For posterior blepharitis, warm compresses applied several times daily help liquefy gland secretions, followed by expression of the glands. In more persistent cases, topical azithromycin or oral doxycycline may be used, though these are avoided in young children and during pregnancy.
An important aspect of management is treating associated evaporative dry eye, which often contributes more to symptoms than the blepharitis itself. This may include artificial tears, punctal plugs, or topical anti-inflammatory therapy such as cyclosporine. Dietary supplementation with omega-3 fatty acids may also provide benefit in meibomian gland dysfunction.
Blepharitis is a lifelong condition with a tendency for recurrence, but the prognosis is excellent with appropriate management, and significant vision loss is not expected. Complications can include chronic dry eye, marginal keratitis, and chalazia. Patient education regarding the chronic nature of the disease and the importance of consistent eyelid hygiene is essential for successful long-term control.
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