BLEPHARITIS: Clinical Pearls for the Primary Care Practitioner.
Author : Leonard Einstein DNP,
APRN, NP-C, FNP-BC
Blepharitis is an inflammation of the eyelids and margins. There are two forms of blepharitis: (1) a nonulcerative form associated with seborrhea of the face and scale and (2) an ulcerative form that may involve the lash follicle and the meibomian glands of the eyelid.
Blepharitis results from inflammation (both infectious and noninfectious) of the structures of the lid margin and presents as lid-margin redness, scaling, and crusting. It is important to differentiate when Blepharitis is caused by Staphylococcus since Staphylococcal blepharitis produces dry scales, lash loss, and sometimes conjunctivitis and corneal limbal infiltrates. ( see fig 1 for Staphylococcal blepharitis).
Fig 1 Staphylococcal blepharitis
Seborrheic blepharitis and meibomian gland dysfunction are associated with chronic oily secretions causing irritation and dilated vessels at the posterior lid margin in association with conjunctiva inflammation; examination of the margin may reveal inspissated sebaceous material. Meibomian gland dysfunction is frequently associated with seborrheic dermatitis and acne rosacea. Blepharitis tends to be chronic with acute flare-ups and is more common in fair-skinned people.
The more common signs and symptoms are conjunctival redness and irritation with dryness and burning of the lid margin. Also, Dandrufflike debris on lid margins and eyelashes can be visualized sometimes. There should not affect visual acuity or cause photophobia. It is also related to and high in incidence in patients that have rosacea and seborrheic dermatitis
Secondary infections may develop with either form, and recurrences are common and frequently persistent. Both types may coexist.
Epidemiology and Causes
Blepharitis is the most common ocular disease, affecting males and females equally. Nonulcerative blepharitis is occasionally seen in those with trisomy 21 and tends to affect people with psoriasis, seborrhea, eczema, allergies, and lice infestations. Poor hygiene is implicated, as well as poor nutritional status, immune suppression, acne rosacea, and yeast infections. Exposure to chemical or environmental irritants, as well as the use of eye makeup and contact lenses, may contribute to the development of this disorder.
Pathophysiology
Although difficult to discern without a full ophthalmological exam, the localization of blepharitis speaks to the differentiation of affected structures. Anterior blepharitis typically affects the eyelash hair follicles along the eyelid’s anterior lamella, whereas posterior blepharitis involves inspissation and inflammation of the meibomian gland orifices (meibomianitis) along the tarsal plate. Seborrheic gland dysfunction, along with accelerated shedding of skin cells, appears to be the primary insult resulting in inflammation in the nonulcerative form, in which an oily crust envelops individual eyelash cilia (seborrheic blepharitis).
The inflammatory, noninfectious skin disorder known as acne rosacea, which commonly affects the cetral face, is another common etiology of blepharitis in the younger population. Blepharitis may also be a manifestation of an allergic process such as a contact dermatitis if a foreign irritant comes into contact with facial skin. In contrast, underlying infection by skin flora, most notably Staphylococcus aureus, produces an ulcerative form that may become chronic, extending to the conjunctivae and cornea, known as blepharoconjunctivitis—a condition with a strong potential to affect eyesight.
Clinical Presentation
Subjective
Both forms of blepharitis may present with complaints of itching and burning, and foreign body sensation in the eye. Sensitivity to bright lights and tearing may also be present. Presentation may be unilateral or bilateral.
Objective
Lid margins are edematous and erythematous. Inspection with a magnifying glass may reveal scaling, erythema, and ulcers. Nonulcerative blepharitis may present with scales along the lid margins that are easily removed. With ulcerative blepharitis, there may be pustules at the base of the hair follicles that may crust and bleed. The lashes become thin and break easily. Use gloves to palpate the lid margins and lid for masses and palpate for preauricular lymphadenopathy.
Diagnostic Reasoning
As a diagnostic test with any eye problem, it is vital to evaluate visual acuity. Any alteration in visual acuity may indicate a potentially serious underlying problem that warrants further investigation and possible referral. If there is a discharge, a culture and sensitivity should be considered. Referral for patients with blepharitis should occur in the following situations: visual loss, moderate to severe pain, chronic redness of the eye, corneal involvement, recurrent blepharitis, and when patients fail to respond to therapy. Any lesion in or around the eye that does not respond to conventional therapy within 1 month should be referred to a specialist for possible biopsy. Persistent inflammation and thickening of the eyelid margin may indicate squamous cell, basal cell, or sebaceous cell carcinoma.
Sebaceous cell carcinoma has a 23% fatality rate; up to one-half of potentially fatal sebaceous cell carcinomas resemble chronic, benign inflammatory disease, particularly chalazion and blepharoconjunctivitis.
Differential Diagnosis
Persistent inflammation and thickening of the eyelid margin may indicate squamous cell, basal cell, or sebaceous cell carcinoma masquerading as blepharitis. Carcinoma may also mimic styes or chalazion.
Any swelling or inflammation of the eyelid that does not resolve promptly (within 1 month) with treatment should be evaluated further.
Treatment usually consist of pharmacological and non pharmacological measures. Warm compresses on the eyelids and then removal of the debris via gentle scrubbing with baby shampoo could help effectively.
Consider topical antibiotics for 7 to 10 days Bacitracin or erythromycin 0.5% ointment thin ribbon on the eyelid border every 6-8 hours after cleaning . Also another alternative treatment could be sulfacetamide/0.2% prednisone (Blephamide) thin ribbon (1⁄2 inch) three times per day and every evening could be considered an alternative treatment after gentle cleansing and using warm compresses. Treatment may continue for 1 or more weeks. The frequency and duration of treatment should be guided by the severity of the blepharitis. For resistant staphylococcal infections, a quinolone antibacterial ointment is appropriate or a sulfacetamide/ corticosteroid combination that, like erythromycin, has been shown to be effective against staphylococci. The combined corticosteroid is useful in decreasing both inflammation and symptoms. Use of the two agents combined has been shown to increase patient compliance. Blephamide is available in an ophthalmic suspension and in an ointment, both containing the same concentrations of active ingredients (10% sulfacetamide/ 0.2% prednisolone).
For Severe cases of Blepharitis which is also associated with Rosacea the best options would be either Oral doxycycline 100 mg PO twice daily or tetracycline 250 mg PO four times daily is appropriate. These are prescribed for several weeks and then tapered. Continued hygienic measures as above.
Follow-up and Referral
The clinician should reevaluate the patient in 2 weeks; if symptoms are improving, the patient should be reevaluated in 2 months. As noted, if there is no resolution in 1 month, the patient should be referred to an ophthalmologist. Vision changes and pain in the eye also warrant referral. Blepharitis may be difficult to resolve, and recurrences are common. Hordeolum, loss of lashes, or misdirection of the eyelashes (trichiasis), scarring, and corneal infection may occur.
Patient Education
Patients should be encouraged to wash their hands often and dry them with clean towels to prevent reinfection or transfer of bacteria or virus to other persons. In addition, patients should be advised to avoid environmental irritants, to use hypoallergenic soap and makeup, and to exercise care in use of contact lenses. The clinician should educate the patient as to the chronic and recurrent nature of this disorder and the need for vigilance in adherence to the treatment plan until the blepharitis is completely resolved. Long-term eyelid hygiene—gently cleansing with diluted baby shampoo daily is required to control this disorder. Eye makeup should not be used until resolution of the disorder, and then the patient should switch to hypoallergenic makeup.
References
Dunphy, L. M., Winland-Brown, J. E., & Thomas, D. J. (2015). CHAPTER 8 Eyes, Ears, Nose, and Throat Problems. In Primary care: The art and science of advanced practice nursing (4th ed., pp. 257-259). F A Davis Company.
Goroll, A. H., & Mulley, A. G. (2014). CHAPTER 199. Evaluation of the Red Eye. In Primary care medicine: Office evaluation and management of the adult patient (7th ed., pp. 3598-3604). Lww.
Fenstermacher, K., & Hudson, B. T. (2015). Chapter 7 Eye, ear, nose, and throat conditions. In Practice guidelines for family nurse practitioners (4th ed., pp. 228-229). W B Saunders Company.Leonard E. APRN FNP-BC , NP-C