BASICS

DESCRIPTION

• Chronic, recurrent inflammation of the eyelid margin

• Synonyms:

– Seborrheic blepharitis: Anterior blepharitis, granulated eyelids

– Meibomian gland dysfunction: Posterior blepharitis, ocular rosacea, meibomianitis

EPIDEMIOLOGY

Prevalence

Common, 37–47% of patients in an ophthalmology or optometry practice

RISK FACTORS

More common in Caucasian from Northern Europe, but found in all races

Genetics

More common if parents had blepharitis

PATHOPHYSIOLOGY

• Seborrheic blepharitis: Large scales of skin form at the surface of the anterior eyelid margin. Secondary bacteria colonization of the area leads to inflammation.

• Meibomian gland dysfunction: An abnormal composition of the meibomian gland lipid secretion leads to inflammation.

ETIOLOGY

• Seborrheic blepharitis: Tends to be inherited and may be due to colonization of the eyelid margin skin with yeast of the Malassezia genus

• Meibomian gland dysfunction: Tends to be inherited

COMMONLY ASSOCIATED CONDITIONS

• Evaporative dry eye and staphylococcal hypersensitivity marginal keratitis/ulcers, phlyctenulosis

• Seborrheic blepharitis tends to be associated with seborrheic dermatitis.

• Meibomian gland dysfunction tends to be associated with acne rosacea and chalazia.

DIAGNOSIS

HISTORY

• Itching and burning of the eyelid margins. Redness of the eyelid margin and conjunctiva. Symptoms fluctuate through the day and through the weeks. Many patients are symptomatic of an evaporative dry eye (see topic Dry Eye Syndrome).

• Patients with seborrheic blepharitis also complain of large flakes of skin at the base of the eyelashes.

• Patients with meibomian gland dysfunction also complain of rounded, protruding, creamy-hard white–yellow deposits at the eyelid margin just posterior to the eye lashes.

PHYSICAL EXAM

• Seborrheic blepharitis: Large scales of skin form at the anterior eyelid margin, hyperemia of the anterior eyelid margin, debris in the tear film, inferior punctate keratitis.

• Meibomian gland dysfunction: White–yellow viscous-waxy plugs in meibomian gland orifices, hyperemia of the entire eyelid margin, eyelid margin vessels crossing the gray line, appearance of a thin lipid layer of the tear film, inferior punctate keratitis. There may also be associated chalazia and skin findings of acne rosacea.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Seborrheic blepharitis: Bacteria can be cultured from the eyelid margin. Small quantities and usually nonvirulent strains may be significant.

Pathological Findings

• Seborrheic blepharitis: The anterior eyelid epidermis shows acanthosis, hyperkeratosis, and/or parakeratosis; lymphocyte and plasma cell infiltrate.

• Meibomian gland dysfunction: Obstruction, dilatation with squamous metaplasia and abnormal keratinization of ducts, enlargement of acini with cystic degeneration and an inflammatory cell infiltrate.

DIFFERENTIAL DIAGNOSIS

Acute bacterial ulcerative blepharitis (usually Staphylococcus aureus), acute viral blepharitis (herpes simplex or herpes zoster)

TREATMENT

MEDICATION

First Line

• Seborrheic blepharitis: If the primary treatment of eyelash scrubs, i.e., gently cleaning the base of the eyelashes with a cotton swab dipped in a dilute solution of baby shampoo (e.g., 2–3 drops in ½ cup of hot water) b.i.d., is insufficient, an antibiotic ointment q.h.s. can be used. The antibiotic should be chosen based on eyelid culture results. Treatment with topical antibiotics may need to be used continuously for up to 3 months and may be needed recurrently.

• Meibomian gland dysfunction: If the primary treatment of ocular hot compresses, i.e., gel or bead filled microwaveable hot compresses (not wash cloth hot compresses) 3–4 times per day for 10–15 min, is insufficient, an antibiotic topical azithromycin or oral doxycycline 100 mg b.i.d. may need to be used recurrently for 3–4 months.

Pediatric Considerations

Doxycycline, tetracycline, and derivatives should not be used in children <8 years of age.

Pregnancy Considerations

Doxycycline, tetracycline, and derivatives should not be used in pregnant or nursing mothers.

Second Line

• The secondary evaporative dry eye usually causes more symptoms than the primary seborrheic blepharitis or meibomian gland dysfunction. Therefore, treating the secondary evaporative dry eye results in more symptomatic improvement than treating the blepharitis and is often instituted first. Only if there are unacceptable residual symptoms after treating the secondary evaporative dry eye, would the seborrheic blepharitis or meibomian gland dysfunction be treated. Treatment for the secondary evaporative dry eye can include moderately viscous and viscous artificial tears, punctal plugs, and topical cyclosporin A drops.

• Oral Omega-3 fatty acid dietary supplements, oral fluconazole, topical azithromycin, rarely topical steroid drops, and/or ointment should be used very rarely, because only short-term improvement results, continuous monitoring is required, and severe vision threatening problems such as glaucoma or steroid enhanced herpes simplex keratitis may result.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

• In seborrheic blepharitis, it can take 2 weeks to know if the eyelash scrubs are helping and 4 weeks to know if the q.h.s. antibiotic ointments are helping.

• In meibomian gland dysfunction, it can take 2 weeks to know if the ocular hot compresses are helping and 4 weeks to know if the doxycycline is helping.

DIET

A diet high in Omega-3 fatty acids will probably improve the symptoms of meibomian gland dysfunction.

PROGNOSIS

Seborrheic blepharitis and meibomian gland dysfunction are lifelong, chronic, recurrent conditions that will respond well to treatment and then will reoccur. Uncomplicated seborrheic blepharitis and meibomian gland dysfunction have an excellent visual prognosis with no visual loss expected.

COMPLICATIONS

Evaporative dry eye and staphylococcal hypersensitivity marginal keratitis/ulcers, phlyctenulosis are complications of seborrheic blepharitis and meibomian gland dysfunction. Meibomian gland dysfunction can be complicated by chalazia.

ADDITIONAL READING

• Shine WE, McCulley JP, Pandya AG. Minocycline effect on meibomian gland lipids in meibomianitis patients. Exp Eye Res 2003;76:417–420.

• Souchier M, Joffre C, Grégoire S, et al. Changes in meibomian fatty acids and clinical signs in patients with meibomian gland dysfunction after minocycline treatment. Br J Ophthalmol 2008;92:819–822.

• Jackson WB. Blepharitis: Current strategies for diagnosis and management. Can J Ophthalmol 2008;43:170–179.

• Macsai MS. The role of Omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction. Trans Am Ophthalmol Soc 2008;106:336–356.

CODES

ICD9

• 370.49 Other keratoconjunctivitis, unspecified

• 373.00 Blepharitis, unspecified

• 373.12 Hordeolum internum

CLINICAL PEARLS

• Treating the secondary evaporative dry eye may lead to more symptomatic improvement than treating the seborrheic blepharitis and meibomian gland dysfunction.

• Use a very dilute solution of baby shampoo for the eyelash scrubs.

• Do not use eyelash scrubs in meibomian gland dysfunction.

• Use gel or bead filled microwaveable hot compresses, wash cloth hot compresses do not stay hot enough for long enough and don’t work

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