Therapeutic Review: Blepharitis -Complications & Management
by Dr Anthony Maloof
Inflammatory disease of the eyelids may lead to complications involving all anatomical components of the eyelids. Typically, this includes the skin, hair follicles, oil glands and conjunctiva. It typically manifests to the patient as red eyes and “styes”. A range of complications occur including telangiectasis of the skin, stye (hordeola), chalazion, angular blepharitis, seborrhoea, lash disorders and marginal keratitis
Hordeola is an acute suppurative nodular inflammation of the eyelid margin (figure 1), affecting primarily the glands of Zeiss, sweat glands or hair follicles of the anterior eyelids. They may also involve the Meibomian glands on the posterior eyelids. They are infectious, commonly staphylococcal, and may rupture spontaneously.
Management: these require hot compresses and topical antibiotics (typically Chloromycetin four times daily).
Commonly presenting as a visible or palpable eyelid lump, this lesion is a sterile, chronic, nodular inflammation of a gland of Zeiss or Meibomian gland (figure 2). Histopathologically, it is a lipogranulomatous reaction with giant cells (figure 3) to sebaceous material that has been extruded from a plugged gland, and forced backwards into the surrounding tissue. It can develop acutely or insidiously, and may be indistinguishable from a hordeola. These are typically located over the tarsal plate, however they may extend beyond the tarsus into the retractors of the eyelids, where they must be differentiated from other more insidious lesions such as tumours or dermoid cysts.
Management: as this is sterile, topical antibiotics are usually NOT beneficial. Hot compresses may be of benefit initially, along with massage to the eyelid margins. Should this fail, incision and drainage typically via a tarsal approach is usually curative.
RECURRENT CHALAZION: although chalazia may well recur, typically in the presence of skin disease or local blepharitis, this entity is a presenting manifestation of the more life threatening disease “Sebaceous Gland Carcinoma” of the conjunctiva, and may pass undiagnosed for months. Recurrent chalazia MUST be fully investigated.
Blepharitis of the eyelids may be focal, occurring at only the lateral aspect of the eyelid margin (figure 4). This is Angular Blepharitis, and is typically associated with Moraxella infection. It is usually bilateral, and associated with conjunctivitis, and the angle is usually wet, macerated and ulcerated. Diagnosis is confirmed with microbiological investigations - on gram stain, a gram negative diplobacillus is seen.
Management: topical antibiotics (typically Chloromycetin) four times daily and an eyelid cleaning regime twice daily until the infection is cleared.
If blepharitis selectively involves the anterior eyelid, the glands of Zeiss and sweat glands are typically affected. Staphylococcal infection of the anterior eyelids is usually associated with collarettes around the base of the lashes (figure 5), which is readily visible at the slit lamp as hard, brittle and fibrinous scales. As the lash grows, these collarettes gradually move up and away from the eyelid margin. Blood vessel dilation may occur (telangiectasis) and there may be thinning or loss of lashes (madarosis). There may be associated inferior diffuse corneal punctate staining. Meibomian gland dysfunction is usually not seen however Hordeola and chalazion may accompany this picture. The role of staphylococcal infection is not entirely clear, as staphylococci are normal flora of the skin and eyelid. One possibility is that exotoxins from the organism may result in eyelid and corneal sequelae. Loss of lashes may also occur in eyelid skin tumours such as Basal Cell Carcinoma, trichomania (the conscious removal of eyelashes) or atopic disease, and appropriate investigations and management must be undertaken. Seborrhoeic blepharitis may be associated with dry eye.
Management: This disorder may be recurrent or very difficult to manage in the presence of underlying skin disease. The patient understanding and acceptance of the chronic nature of this disorder is critical to the success of management. Lid cleansing typically with a dilute sodium bicarbonate solution, or LidCare® combined with a smearing of topical antibiotics to the eyelid margin will have the greatest affect, provided this is carried out routinely twice daily, for at least 1 month. In some cases, supplementation with weak topical steroids may be beneficial to control the secondary conjunctival inflammation, and used cautiously. If the patient is symptomatic of dry eye, then this should be management with topical lubricants as necessary.
This is quite a complex disorder, and typically misdiagnosed. As it is so common, and causes significant patient morbidity, its presentation and management should be a stand alone topic, and will be dealt with in full in the next issue.
I would like to thank Dr Anthony Maloof for his great therapeutic summaries so far. His expertise in anterior segment disease, cataract surgery and oculoplastics is an invaluable contribution to this monthly newsletter.
Anthony would welcome your enquiries at:
Phone: 1300 303 669
Rooms (Sydney city):
Suite 13, Level 9, William Bland Building, 229-231 Macquarie St Sydney 2000
Suite 7, The Ashley Centre, 1a Ashley Lane, Westmead 2145
Blepharitis deserves to be in a whole days seminar. Register your interest for Ocular Therapeutics 2006 , which will devote a session to the diagnosis and management of this ocular disease. Efficient implementation of ocular therapeutics is another great way to differentiate your practice and thus make you more profitable.