Aetiology

Blepharitis is a chronic inflammation with possible acute exacerbations that primarily affects the eyelid margins and is one of the most common presentations in primary eye care. Blepharitis is conventionally classified as:

Anterior blepharitis (also known as Anterior Lid Margin Disease)

• bacterial (usually staphylococcal)
  • caused by (1) direct infection, (2) reaction to staphylococcal exotoxin or (3) allergic response to staphylococcal antigen
• seborrhoeic (disorder of the ciliary sebaceous glands of Zeis).
• Demodex folliculorum infestation of the lash follicles

Posterior blepharitis (also known as Posterior Lid Margin Disease)

• meibomian gland dysfunction (MGD)
  • bacterial lipases break down meibomian lipids
  • meibomian secretion becomes abnormal both chemically and physically
  • plugging of duct orifices with abnormal lipid leading to dilatation of glands and potential formation of microliths and chalazia
  • tear film becomes unstable.

Mixed anterior and posterior blepharitis

• elements of both conditions are present.

All of these conditions are typically bilateral, overlapping, chronic and relapsing.

Dry Eye Disease is present in:

• 50% of people with staphylococcal blepharitis
• 25-40% of people with seborrhoeic blepharitis.

Posterior blepharitis is a leading cause of evaporative dry eye.

A significant association has been found between Demodex infestation and blepharitis (see evidence base). Although Demodex mites are found on healthy, asymptomatic individuals it has been suggested that the mites may play a pathogenic role at higher density. Though the precise role of the mite in the pathogenesis of the condition is unclear; it may be due to direct damage, increasing bacterial colonisation or inducing an inflammatory response.

Predisposing factors

Seborrhoeic dermatitis (for example, of the face and/or scalp).

Ocular rosacea (a cause of posterior blepharitis).

Demidicosis

• Demodex folliculorum found in the lash follicles
• Demodex brevis found in meibomian glands.

Long-term contact lens wear.

Symptoms of blepharitis (lid margin disease)

Blepharitis may be asymptomatic. However, when present, the symptoms of anterior blepharitis, posterior blepharitis and mixed anterior and posterior blepharitis are similar:

• ocular discomfort, soreness, tearing, burning, itching
• itching of the eyelids is a common symptom in demodex blepharitis
• mild photophobia
• symptoms of dry eye including blurred vision and contact lens intolerance.

Signs of blepharitis (lid margin disease)

Anterior blepharitis (staphylococcal)

• crusting of anterior lid margin (scaly deposits at bases of lash)
• lid margin swelling and hyperaemia
• secondary signs include: misdirection of lashes; loss of lashes (madarosis), recurrent hordeola (styes) and (rarely) chalazia; punctate epithelial erosion over lower third of cornea; marginal keratitis; phlyctenulosis; neovascularisation and pannus; mild papillary conjunctivitis.

Anterior blepharitis (seborrhoeic)

• lid margin hyperaemia
• oily or greasy deposits on lashes and/or lid margins

Anterior blepharitis (Demodex)

• lid margin hyperaemia
• collarettes 'cylindrical dandruff’ are considered to be pathognomic for Demodex blepharitis: characteristic clear sleeve (collarette) covers base of lash, extending further up lash than flat staphylococcal rosettes
• persistent infestation of the lash follicles may lead to misalignment, trichiasis or madarosis.

Posterior blepharitis (MGD is the most common cause)

• thick and/or opaque secretion at meibomian gland orifices, making it difficult or impossible to express oil by finger pressure
• foam in the lower tear film meniscus
• plugging of duct orifices
• lid margin and conjunctival hyperaemia
• evaporative tear deficiency, unstable pre-corneal tear film
• secondary signs include: punctate epithelial erosion over lower third of cornea; marginal keratitis; scarring; neovascularisation and pannus; mild papillary conjunctivitis; chalazia, meibomian gland dropout (for management, see appropriate CMGs where available)

Differential diagnosis

Allergy
Dermatoconjunctivitis medicamentosa (see Clinical Management Guideline on Conjunctivitis Medicamentosa).
Eyelid dermatitis.
Parasitic infestation (e.g. Phthirus pubis infestation of lid margins).
Preseptal cellulitis.
Herpes (simplex or zoster).
Meibomian gland carcinoma (usually unilateral).

Management by optometrist

Practitioners should work within their scope of practice and where necessary seek further advice or refer the patient elsewhere.

GRADE* level of evidence and strength of recommendation always relates to the statement(s) immediately above.

Management of Dry Eye Disease, if also present: see Clinical Management Guideline on Dry Eye Disease.

Patients should be made aware of the chronic nature of the condition and the need of on-going treatment.

Lid hygiene, consisting of lid cleansing and vertical massage using a variety of measures, is the first line of management regardless of type of blepharitis.

Lid cleansing measures wipe away bacteria and deposits from lid margins and lead to improved signs and symptoms in the majority of individuals. However, there is insufficient high quality evidence on the comparative efficacy of the various lid hygiene regimes. There is evidence that long-term compliance with lid hygiene measures may be poor.
(GRADE*: Level of evidence = moderate, Strength of recommendation = strong)

Wet warm compresses loosen collarettes and crusts in anterior blepharitis. Dry warm compresses melt meibum in posterior blepharitis (compress applied to lid skin twice daily for not less than 5 minutes at 40°C. Commercial products and electronic heating devices are available that are able to maintain temperatures in this region).
(GRADE*: Level of evidence = weak, Strength of recommendation = strong)

Intense Pulsed Light (IPL) therapy has been recommended for the management of meibomian gland dysfunction (MGD). However, a 2020 Cochrane Review found a lack of evidence as to the effectiveness and safety of this treatment modality.
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

During exacerbations, advise the avoidance of cosmetics along the eyelid margin, especially eye liner and mascara. Advise patient to return/seek further help if symptoms persist.

Complete eradication of the blepharitis may not be possible, but long-term compliance with these measures should reduce symptoms and minimise the number and severity of relapses.

Staphylococcal and seborrhoeic blepharitis may benefit from short-term topical antibiotics if not controlled by first line management

• antibiotic ointment (e.g. chloramphenicol) twice daily; place in eyes or rub into lid margin with fingertip
• short course of topical azithromycin (NB off-label use).

(GRADE*: Level of evidence = moderate, Strength of recommendation = weak)

In patients with posterior blepharitis, systemic antibiotics may be effective as a second line treatment

• consider prescribing a systemic tetracycline, such as doxycycline or minocycline (contraindicated in pregnancy, lactation and in children under 12 years; various adverse effects have been reported). Such treatment will need to be continued for several weeks or months and the dosage may need to be varied from time to time
• where tetracyclines are contraindicated, consider prescribing oral
  erythromycin or azithromycin

A 2021 Cochrane review reported that there is insufficient evidence on the use of oral antibiotics for chronic blepharitis. Low certainty evidence found that oral antibiotics could improve clinical signs compared to placebo, but may cause more adverse events.
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Consider short-term mild topical steroids in patients with severe symptoms
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Demodex blepharitis is commonly treated with lid margin cleaning with tea tree oil, although there is uncertainty regarding its effectiveness. However, if used, lower concentrations are recommended to avoid ocular toxicity. Preparations e.g. cleaning wipes containing 4-terpineol (the proposed active ingredient of tea tree oil) are commercially available for patient use.
(GRADE*: Level of evidence = low, Strength of recommendation = weak)

Management category

B2: alleviation/palliation: normally no referral.

In patients who do not respond to therapy the possibility of carcinoma or
immune mediated diseases should be considered, particularly if the blepharitis is associated with loss of eyelashes and/or cicatricial changes.

A3: in unilateral cases, if meibomian gland carcinoma is suspected, refer urgently (within one week) to ophthalmologist.

Possible management in secondary care or local primary/community pathways where available

Microbiological investigations including culture and sensitivity testing. To minimise risk of post-operative infection, some clinicians propose active management of blepharitis prior to penetrative ocular surgery (e.g. trabeculectomy) or intra-vitreal injection.

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)

Sources of evidence

Ayres BD, Donnenfeld E, Farid M, Gaddie IB, Gupta PK, Holland E, Karpecki PM, Lindstrom R, Nichols KK, Pflugfelder SC, Starr CE, Yeu E. Clinical diagnosis and management of Demodex blepharitis: the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Eye (Lond). 2023;37(15):3249-3255.

Bilkhu PS, Naroo SA, Wolffsohn JS. Randomised masked clinical trial of the MGDRx EyeBag for the treatment of meibomian gland dysfunction-related evaporative dry eye. Br J Ophthalmol. 2014;98(12):1707-11

Cote S, Zhang AC, Ahmadzai V, Maleken A, Li C, Oppedisano J, Nair K, Busija L, Downie LE. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev 2020: 3: CD013559

Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O’Brien T, Rolando M, Tsubota K, Nichols KK. The International Workshop on Meibomian Gland Dysfunction: Report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050-2064

Jones L, Downie LE, Korb D, Benitez-Del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu Y, Seo KY, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II Management and therapy report. Ocul Surf. 2017;15(3):575-628

Kashkouli MB, Fazel AJ, Kiavash V, Nojomi M, Ghiasian L. Oral azithromycin versus doxycycline in meibomian gland dysfunction: a randomised double-masked open-label clinical trial. Br J Ophthalmol. 2015;99(2):199-204

Lin A, Ahmad S, Amescua G, Cheung AY, Choi DS, Jhanji V, Mian SI, Rhee MK, Viriya ET, Mah FS, Varu DM; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Blepharitis Preferred Practice Pattern. Ophthalmology. 2024;131(4):P50-P86.

Lindsley K, Matsumura S, Hatef E, Akpek EK. Interventions for chronic blepharitis. Cochrane Database Syst Rev 2012, 5: CD005556

Navel V, Mulliez A, Benoist d'Azy C, Baker JS, Malecaze J, Chiambaretta F, Dutheil F. Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis. Ocul Surf. 2019; 17(4):655-669

Onghanseng N, Ng SM, Halim MS, Nguyen QD Oral antibiotics for chronic blepharitis. Cochrane Database Syst Rev. 2021;6(6):CD013697

Pflugfelder SC, Karpecki PM, Perez VL. Treatment of blepharitis: recent clinical trials. Ocul Surf. 2014;12(4):273-84

Sabeti S, Kheirkhah A, Yin J, Dana R. Management of meibomian gland dysfunction: a review. Surv Ophthalmol. 2020;65(2):205-207

Savla K, Le JT, Pucker AD Tea tree oil for Demodex blepharitis. Cochrane Database Syst Rev 2020;6(6):CD013333

Sung J, Wang MTM, Lee SH, Cheung IMY, Ismail S, Sherwin T, Craig JP. Randomized double-masked trial of eyelid cleansing treatments for blepharitis. Ocul Surf. 2018;16(1):77-83

Zhang AC, Muntz A, Wang MTM, Craig JP, Downie LE. Ocular Demodex: a systematic review of the clinical literature. Ophthalmic Physiol Opt. 2020;40(4):389-432

Zhang L, Wang J, Gao Y. Eyelid cleaning: Methods, tools, and clinical applications. Indian J Ophthalmol. 2023;71(12):3607-3614

Zhao YE, Wu LP, Hu L, Xu JR. Association of blepharitis with Demodex: A meta-analysis. Ophthalmic Epidemiology 2012;19(2),95-102

Blepharitis (Lid Margin Disease)
Version 18
Date of search 16.03.24
Date of revision 02.05.24
Date of publication 10.06.24
Date for review 15.03.26
© College of Optometrists