Blepharitis
Chronic inflammation of the eyelid margin — anterior (Staph/seborrheic) or posterior (meibomian gland dysfunction).
Also known as: blepharitis, anterior blepharitis, posterior blepharitis, meibomian gland dysfunction, MGD
Overview
Chronic inflammation of the eyelid margins. Anterior blepharitis affects the base of the lashes and is staphylococcal or seborrheic. Posterior blepharitis affects the meibomian gland orifices — meibomian gland dysfunction (MGD) — and is the most common form, frequently associated with ocular rosacea.
Epidemiology
Among the most common ocular complaints in primary care and ophthalmology. Prevalence increases with age; coexists with dry eye disease, rosacea, seborrheic dermatitis, and atopic dermatitis.
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Risk factors
- Rosacea (cutaneous or ocular)
- Seborrheic dermatitis
- Atopic dermatitis
- Demodex mite infestation (especially elderly)
- Contact lens wear
- Isotretinoin therapy (worsens MGD)
- Androgen deficiency / post-menopause
Pathophysiology
Anterior blepharitis: bacterial colonization (mostly S. aureus) and seborrheic scaling of the lash follicles lead to inflammation. Posterior blepharitis/MGD: meibomian gland orifices become obstructed by abnormally viscous secretions, lipase-producing bacteria alter tear film lipid layer, and chronic inflammation results in evaporative dry eye. Demodex folliculorum/brevis mites can contribute via mechanical and inflammatory effects with characteristic cylindrical lash dandruff.
Clinical presentation
Symptoms
- Chronic burning, itching, foreign body sensation
- Crusting and stickiness of eyelids on awakening
- Eye redness, tearing or paradoxical dryness
- Recurrent styes or chalazia
- Photophobia and intermittent blurred vision (tear film instability)
- Often bilateral, waxing and waning
Signs / physical exam
- Anterior: scaling and collarettes at base of lashes; lash loss (madarosis), misdirected lashes (trichiasis); eyelid margin erythema
- Posterior/MGD: capped or plugged meibomian gland orifices, frothy tear film, telangiectasias along posterior lid margin, thickened lid margin
- Demodex: cylindrical 'sleeves' of waxy material at lash base
- Punctate epithelial erosions on cornea with rapid tear break-up
- Concurrent rosacea findings on face: malar erythema, telangiectasias, rhinophyma
Classic findings
Anterior collarettes vs capped meibomian glands with frothy tears — often coexist.
Differential diagnosis
- Dry eye disease (aqueous deficient) — Burning, foreign body sensation, often coexists with MGD; Schirmer test, tear break-up time
- Allergic conjunctivitis — Bilateral itching, atopic history, chemosis
- Bacterial conjunctivitis — Acute purulent discharge, eyelids matted shut, less chronic
- Contact dermatitis of lid — Erythema/scaling of lid skin, recent exposure to allergen or topical drop
- Sebaceous gland carcinoma — Unilateral chronic 'blepharitis' or recurrent chalazion with lash loss in older adult; biopsy
- Demodicosis — Cylindrical dandruff at lash base; treat with tea tree oil-based lid scrubs
- Cicatricial pemphigoid / Stevens-Johnson sequelae — Symblepharon, lid scarring; immunopathology
Diagnostic workup
Labs
- Clinical diagnosis — no labs routinely required
- Culture of lid margin if severe, recurrent, antibiotic failure, or contact lens wearer (rule out MRSA, atypical organisms)
- Consider TSH and dermatologic evaluation in unusual presentations
Imaging
- Slit-lamp examination: lid margin, meibomian gland expression, tear film evaluation, fluorescein staining for corneal involvement
- Meibography (optional) to quantify gland dropout in chronic MGD
Diagnostic algorithm
| Feature | Anterior Blepharitis | Posterior Blepharitis (MGD) |
|---|---|---|
| Location | Lash base / anterior lamella | Meibomian gland orifices / posterior lamella |
| Etiology | Staphylococcal or seborrheic | Meibomian gland dysfunction; ocular rosacea |
| Key sign | Collarettes, lash crusting, madarosis | Capped glands, frothy tears, telangiectasias |
| Associated condition | Seborrheic dermatitis, atopy | Rosacea, dry eye |
| First-line therapy | Lid hygiene + topical antibiotic ointment | Warm compresses + gland expression |
| Adjunctive therapy | Topical steroid for flares | Oral doxycycline; cyclosporine; IPL/LipiFlow |
Treatment
First-line
- Warm compresses 5-10 minutes 1-2 times daily — soften meibomian secretions
- Eyelid massage and expression of meibomian glands after warming
- Lid hygiene with dilute baby shampoo, commercial lid scrub pads, or hypochlorous acid spray
- Artificial tears (preservative-free) for tear film support
- Treat coexisting dry eye and rosacea
Second-line / adjunct
- Topical ocular antibiotic for anterior blepharitis — erythromycin ointment, bacitracin ointment, or azithromycin 1% drops — applied to lid margin nightly for 2-8 weeks
- Topical/oral corticosteroid (short course) — loteprednol 0.5% drops, or oral prednisone — for flares; monitor IOP
- Oral tetracycline-class for posterior blepharitis/MGD or ocular rosacea — doxycycline 50-100 mg BID, minocycline 50-100 mg daily, or tetracycline 250 mg QID — 6-12 weeks then taper; avoid in pregnancy/children <8
- Topical cyclosporine 0.05% BID or lifitegrast 5% BID for associated dry eye
- Tea tree oil 50% lid scrubs (e.g., Cliradex) weekly for Demodex blepharitis
- In-office thermal pulsation (LipiFlow) or intense pulsed light for refractory MGD
- Treat coexisting rosacea with topical metronidazole, ivermectin, or oral therapy
Complications
- Chronic dry eye disease and tear film dysfunction
- Recurrent hordeola and chalazia
- Conjunctivitis and marginal keratitis (corneal infiltrates from staphylococcal hypersensitivity)
- Corneal neovascularization, scarring, ulceration in severe disease
- Contact lens intolerance
- Trichiasis and madarosis
PANCE pearls
- Blepharitis is chronic — patients must understand it is managed, not cured. Adherence to daily lid hygiene is everything.
- Posterior blepharitis (MGD) is the most common form and the leading cause of evaporative dry eye.
- Oral doxycycline works in MGD through its anti-inflammatory and anti-lipase effects, not antibacterial activity — dose lower than for infection.
- Cylindrical dandruff at the lash base = Demodex — treat with tea tree oil-based lid scrubs.
- Marginal corneal infiltrates with a clear corneal interval at the limbus are immune-mediated reactions to staphylococcal antigen — treat the lids and add topical steroid.
- Unilateral 'blepharitis' that does not respond to standard therapy in an older patient — think sebaceous gland carcinoma and refer for biopsy.
References
- AAO 2018 — American Academy of Ophthalmology. Blepharitis Preferred Practice Pattern. Ophthalmology 2019;126(1):P56-P93
- TFOS DEWS II — Nelson JD et al. TFOS DEWS II Introduction. Ocul Surf 2017;15(3):269-275 (and MGD/Definition reports)
- Cochrane 2012 — Lindsley K et al. Interventions for chronic blepharitis. Cochrane Database Syst Rev 2012;5:CD005556
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