Blepharitis, marginal

Blepharitis is a topical inflammation of the eyelid margins that should be treated using topical antibacterial agents. Gentamicin eye ointment is preferred to the fusidic acid drops since the ointment is a better formulation to be used where the condition involves the eyelid margins. Chloramphenicol eye drops is the third option since it is an antibiotic with a wider spectrum of activity. A combination of corticosteroid and antibiotic is not recommended because of the side-effects associated with the steroid. The use of oral tablets is not usually recommended since blepharitis can easily be managed with topical drops. The use of dexamethasone eye drops, monotherapy steroid, could clear the inflammation but mask persistence of infection. 

Application of solutions or ointments directly to the lid margin is especially helpful in treating seborrheic or infectious blepharitis. After several drops of the antibiotic solution or detergent, such as baby shampoo, are placed on the end of a cotton-tipped appUcator, the solution is applied to the Ud margin with the eyeUds either opened or closed (Figure 3-11). Antibiotic ointments are applied in the same way. 

Blepharitis is a broad term that refers to a collection of lid margin inflammatory disorders that cause changes in adjacent or surrounding structures and often includes, or is associated with, dermatologic conditions such as seborrhea and rosacea. The etiology remains poorly understood despite a strikingly high prevalence in the population it has been reported that approximately 590,000 patients per year seek care due to blepharitis, and it is estimated that 20 million people suffer from this disorder worldwide. 

Mixed seborrheic-staphylococcal blepharitis Posterior lid margin Meibomian gland dysfunction Meibomian seborrhea Meibomitis Primary Secondary... 

Modified from Smith RE, Flowers CW Jr. Chronic blepharitis a review. QAOJ 1995 21 200-207 McCulleyJP, Doughert/JM, Deneau DG. Classification of chronic blepharitis. Ophthalmology 1982 89 1 173-1 180 and Wilhelmus KR. Inflammatory disorders of the eyelid margins and eyelashes. Ophthalmol Clin North Am 1992 5 187-194. 

The exact etiology of eyelid margin disease remains poorly understood, making the diagnosis and treatment a frustrating endeavor for both the patient and the eye care professional. Blepharitis in most forms has no cure, and treatment is meant to quell the acute phase only. 

For many years S. aureus exotoxins have been considered the cause of associated conditions snch as blepharo-keratoconjunctivitis. It has been determined that all Staphylococcus species produce exotoxins, and becanse these species are foimd on the Uds of both normal and blepharitis patients, they are most likely not primarily responsible for the findings. More recent evidence suggests that an abnormal blink mechanism or destabilization of the tear film due to bacterial Upolytic enzyme pathways and increased hydrolysis of phosphoUpids may be the canse. It has also been shown that a delayed hypersensitivity to these toxins can prodnce the marginal keratitis seen in many patients. 

Figure 23-7 Greasy lashes and scurf in seborrheic blepharitis. Note the external hordeolum (stye) on the lower lid margin black arrow). (From Kanski JJ. EyeUds. In Clinical ophthalmology a systematic approach. Philadelphia Butterworth-Heinemann, 2003 10.)...

Figure 23-10 Rosacea with severe blepharitis. Note the thickened lid margins and the corneal neovascularization. This is the same patient as seen in Figure 23-9. (From Palay DA, Krachmer JH. Conjunctival abnormalities. In Primary care ophthalmology, ed. 2. Philadelphia Mosby, 2005 98.)...

Diagnosis. In the classic form, vesicles form along the eyelid margin and/or periocular skin (Figure 23-16). The lesions are clear, pinhead in size, and have an inflamed erythematous base.Typically, within 1 week of presentation the vesicles break and ulcerate, resulting in a painful edematous blepharitis or dermatitis.The involved portion of the lid usually demonstrates mild swelling and tenderness. Pronounced conjunctival injection, a secondary follicular conjunctivitis, a weepy wet eye, and a regional lymphadenopathy may all be present. 

Figure 23-19 (A-C) Cylindrical sleeves (arrows) that rest on the lid margin as seen in Demodex blepharitis. (Gao Y, Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff, Invest Ophthalmol Vis Sci 2005 46 3089-3094).

Trichiasis is an acquired condition in which some or all of the eyelashes are directed inward toward the globe. It is most often the result of aging however, it may also be caused by an inflammatory process or trauma that causes scarring and fibrosis around the eyelash follicles at the lid margin. Potential etiologies include cicatricial conjimctivi-tis, trachoma, herpes simplex and herpes zoster, chronic blepharitis, lacerations, burns, and postsurgical procedures. 

SPK with a bacterial origin usually is associated with blepharitis, the most common cause of which is infection of the lid margins and glands with Staphylococcus. Additionally, conjunctivitis from organisms such as Streptococcus, Moraxella, and Haemophilus may also cause SPK. 

Patients with SPK typically report ocular foreign body sensation, photophobia, redness, and tearing. Patients with an associated blepharitis or blepharoconjunctivitis may also complain of debris on the lids and redness of their lid margins as well as previous episodes, characterized by exacerbations and remissions. If there is a concurrent conjunctivitis, the patient may note an ocular discharge and difficulty opening the lids in the morning. 

Associated ocular and periocular findings also help determine the cause. In blepharitis the Ud margins usually are thickened, red, and scaly lashes may be missing (madarosis). With bacterial conjunctivitis, there is infection of the conjunctiva and a mucopurulent discharge. 

A thorough history and examination is important to determine the cause of phlyctenulosis. Inspect the lid margins for signs of staphylococcal blepharitis and question the patient regarding recent infections or tuberculosis exposure. If there is reason to suspect tuberculosis or if no other cause can be found, a tuberculin skin test may be indicated. If diarrhea or gastrointestinal distress is present, consider a stool examination for nematodes. 

Marginal blepharitis (various organisms) Oiintnent containing adrenal steroid and an antimicrobial. Undue persistence can be due to allergy to treatment. 

Blepharitis Is chronic Inflammation of the lid margins, affecting both eyes. 

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