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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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
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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