Blepharitis of the eyelids: scaly, demodectic, allergic, seborrheic, ulcerative

Blepharitis is a bilateral inflammation of the eyelid margins that can be acute or chronic. Symptoms include itching, burning, redness, and swelling of the eyelids.

Diagnosis is based on anamnesis and examination. In acute ulcerative blepharitis, topical antibiotics are usually prescribed, as well as systemic antiviral agents. In acute non-ulcerative blepharitis, topical glucocorticoids may be prescribed. Chronic disease requires eyelid hygiene (seborrheic blepharitis), wet compresses (dysfunction of the meibomian glands), and tear substitutes (seborrheic blepharitis, dysfunction of the meibomian glands).

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What causes blepharitis?

Depending on the etiology, a distinction is made between infectious (primary), inflammatory, or non-inflammatory blepharitis. Infectious blepharitis is most often caused by bacteria (Staphylococcus aureus, S. epidermidis, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella lacunata), and is likely to be caused by viruses (herpes simplex virus, herpes zoster virus, molluscum contagiosum), fungi (Pityrosporum ovale and P. orbiculare), arthropods (mites - Demodex folliculorum humanis and D. brevis, lice - Phthirus pubis). Non-infectious blepharitis most often develops with seborrhea, rosacea, eczema. Blepharitis is much more often diagnosed in pensioners and with immunodeficiency of various etiologies (HIV, immunosuppressive chemotherapy).

Blepharitis may be acute (ulcerative or nonulcerative) or chronic (seborrheic blepharitis or meibomian gland dysfunction). Acute ulcerative blepharitis is usually caused by a bacterial infection (usually staphylococcal) of the eyelid margin at the origin of the eyelashes, involving the eyelash follicles and meibomian glands. It may also be caused by viruses (eg, herpes simplex virus, herpes zoster virus). Acute nonulcerative blepharitis is usually caused by an allergic reaction involving the same area (eg, atopic blepharodermatitis, seasonal allergic blepharoconjunctivitis, contact dermatoblepharoconjunctivitis).

Chronic blepharitis is a non-infectious inflammation of unknown etiology. Seborrheic blepharitis is often combined with seborrheic dermatitis of the face and scalp. Secondary bacterial colonization often occurs on the scales that form on the edges of the eyelids.

The meibomian glands of the eyelids produce lipids (meibum) that stabilize the tear film by forming a lipid layer in front of the aqueous layer, reducing its evaporation. In meibomian gland dysfunction, the lipid composition is abnormal, the ducts and openings of the glands are filled with waxy plugs, and most patients experience increased tear evaporation and "dry" keratoconjunctivitis. The disease is often associated with rosacea and a history of recurrent styes or chalazion.

Secondary blepharitis - from the lacrimal ducts, sinuses, conjunctiva. In infectious blepharitis, the pathogens are most often staphylococci, streptococci, herpes simplex and herpes zoster viruses, molluscum contagiosum, pathogenic fungi, and possibly arthropod damage (ticks and lice). Non-infectious blepharitis occurs with seborrhea, rosacea, eczema.

The disease blepharitis mainly affects children and young people.

Blepharitis begins in early childhood and often lasts for many years. Blepharitis is caused by unfavorable sanitary and hygienic conditions, work in poorly ventilated, dusty and smoky rooms; in rooms where the air is polluted with chemicals. The general condition of the body is of great importance in the development of blepharitis. Blepharitis is more common with seborrhea, eczematous skin lesions or a tendency to them, anemia, vitamin deficiency, scrofula, and chronic gastrointestinal diseases accompanied by stagnation in the systemic circulation. The disease is often combined with pathological chronic processes in the nasal cavity (graphic and hypertrophic rhinitis, polyps), nasopharynx (enlarged tonsils) and paranasal sinuses.

The development of blepharitis is also facilitated by refractive anomalies, especially hyperopia and astigmatism, as well as age-related changes in accommodation (presbyopia), which are not corrected in a timely manner with appropriate lenses.

Thin, delicate skin, which is more common in fair-haired people, predisposes to the development of blepharitis.

Classification of chronic blepharitis

1. Front

1. staphylococcal
2. seborrheic
3. mixed

2. Back

1. meibomian seborrheic
2. meibomite

3. Mixed (front and back)

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Symptoms of Blepharitis

Common symptoms for all blepharitis include itching and burning of the eyelids, as well as irritation of the conjunctiva with lacrimation and photophobia.

In acute ulcerative blepharitis, small pustules form in the eyelash follicles, which eventually disintegrate to form superficial marginal ulcers. Tightly adherent crusts leave a bleeding surface after removal. During sleep, the eyelids stick together with dried secretions. Recurrent ulcerative blepharitis can cause loss of eyelashes and scarring of the eyelids.

In acute non-ulcer blepharitis, the edges of the eyelids become swollen and reddened; the eyelashes may become covered with crusts of dried serous fluid.

In seborrheic blepharitis, greasy, easily detachable scales form on the edges of the eyelids. In case of dysfunction of the meibomian glands, examination reveals dilated, compacted openings of the glands, from which, when pressed, a waxy, dense, yellowish secretion is released. Most patients with seborrheic blepharitis and dysfunction of the meibomian glands have secondary "dry" keratoconjunctivitis, which is characterized by a sensation of a foreign body, sand, eye strain and fatigue, and blurred vision with prolonged visual strain.

Blepharitis: types

Depending on the localization of the process, anterior (anterior marginal blepharitis) and posterior (posterior marginal blepharitis) eyelid plates are distinguished.

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Scaly (seborrheic) blepharitis

Scaly (seborrheic) blepharitis is characterized by typical symptoms: the appearance of a large number of small scales on the surface of the skin of the eyelid margin and eyelashes, which resemble dandruff. The patient complains of burning, itching, heaviness of the eyelids, rapid eye fatigue. The edges of the eyelids are usually reddened and thickened. Symptoms of progression of the inflammatory process: smoothing of the anterior and posterior edges of the free edge of the eyelid and impaired adaptation of the lower eyelid to the eyeball. Scaly blepharitis is often combined with chronic conjunctivitis and is often accompanied by marginal keratitis. The disease is usually bilateral, as a result of which, in case of long-standing unilateral pathology, it is necessary to exclude a tumor lesion of the eyelid.

In case of scaly blepharitis, daily applications with alkaline solutions will be required to soften the scales, followed by cleaning the edges of the eyelids with a mixture of alcohol and ether or a solution of brilliant green. This procedure is carried out with a slightly wet cotton swab so that the alcohol does not get into the conjunctival cavity. In addition to all this, 1-2 times a day, 0.5% hydrocortisone ointment is applied to the edges of the eyelids (a course of up to 2-3 weeks). A 0.25% solution of zinc sulfate is instilled into the conjunctival cavity.

Ulcerative (staphylococcal) blepharitis

Ulcerative (staphylococcal) blepharitis is characterized by the formation of purulent crusts, adhesion of eyelashes, ulceration of the skin of the edges of the eyelids. In this form of blepharitis, the involvement of hair follicles in the pathological process (folliculitis) causes shortening and fragility of the eyelashes, scarring of the edge of the eyelid, which sometimes leads to abnormal growth, graying or loss of eyelashes. In severe cases, a bacteriological study of a smear from the surface of the ulcer is carried out.

In ulcerative blepharitis, the edges of the eyelids are cleaned in the same way as in the scaly form of the disease. Also, in case of bacterial infection, ointments are applied to the edges of the eyelids 2-3 times a day, under the influence of which the crusts soften, after which they are easier to remove; you can make applications of gauze strips soaked in an antibiotic solution (0.3% gentamicin solution) up to 3 times a day for 4 days. An ointment with an antibiotic (tetracycline, erythromycin) is selected according to the results of a bacteriological study; eye ointments containing antibiotics and corticosteroids are often used (Dexa-Gentamicin, Maxitrol). Local application of 0.25% zinc sulfate solution, 0.3% cipromed solution is possible.

Posterior (marginal) blepharitis, or dysfunction of the meibomian glands

Posterior (marginal) blepharitis, or dysfunction of the meibomian glands, is characterized by a local or diffuse inflammatory reaction: reddening and thickening of the eyelid margins, formation of telangiectasias at the blocked openings of the meibomian glands, their hypo- or hypersecretion, accumulation of yellowish-gray foamy secretion in the outer corners of the eye slit and at the posterior edge of the free edge of the eyelids, hyperemia of the palpebral conjunctiva, and disruption of the precorneal film. When squeezing the edge of the eyelid between a finger and a glass rod, foamy secretion comes out of the meibomian glands.

In case of dysfunction of the meibomian glands, daily treatment of the eyelid margins is required according to the previously described method, the use of alcohol with ether, the use of warm alkaline lotions (2% sodium bicarbonate solution) for 10 minutes. Massage the eyelids with a glass rod after a single instillation of a 0.5% dicaine solution. It is advisable to lubricate the eyelid margins with Dexa-Gentamicin or Maxitrol ointment, and in case of persistent course of the eye, 0.5% hydrocortisone ointment (up to 2 weeks).

Demodectic blepharitis

Demodectic blepharitis is manifested by reddening and thickening of the edges of the eyelids, the presence of scales, crusts, white cuffs on the eyelashes. The mite settles in the lumens of the meibomian glands, eyelash follicles. The main complaint of patients is itching in the eyelid area. If the demodectic nature of blepharitis is suspected, five eyelashes are removed from each eyelid for diagnostic purposes and placed on a glass slide. The diagnosis of demodectic blepharitis is confirmed by detecting larvae around the root of the eyelash and six or more mobile mites. Detection of a smaller number of individuals indicates only carriage (normally, among healthy individuals, it reaches 80%).

After cleaning the edges of the eyelids with a mixture of alcohol and ether, massage the eyelids, and then at night, generously lubricate the free edges of the eyelids with neutral ointments (Vaseline, Vidisik-gel), and in case of concomitant bacterial flora, use combined ointments containing an antibiotic and a corticosteroid ("Dexa-Gentamicin", "Maxitrol") in a short course. Anti-inflammatory and desensitizing drugs are taken internally, Trichopolum can be prescribed.

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Anterior blepharitis

Symptoms of anterior blepharitis: burning, a feeling of "sand", moderate photophobia, crusts and redness of the edges of the eyelids. Usually, by morning, the condition of the eyelids worsens. Surprisingly, there is often no correlation between the presence of complaints and the severity of the disease.

Symptoms of anterior blepharitis

• staphylococcal blepharitis is characterized by hyperemia and telangiectasia of the anterior edge of the eyelid with hard scales, localized mainly at the base of the eyelashes (clamps);
• Seborrheic blepharitis is characterized by hyperemia and a greasy coating on the anterior edge of the eyelid, and stuck together eyelashes. Soft scales are scattered along the edge of the eyelid near the eyelashes;
• Severe chronic anterior blepharitis, especially staphylococcal, may lead to hypertrophy and cicatricial changes of the eyelid margin, madarosis, trichiasis and poliosis.

Combination with other eye manifestations

• When the infection spreads to the Moll and Zeis glands, external stye may differ.
• In 30-50% of cases, instability of the tear film is observed.
• Hypersensitivity to staphylococcal exotoxin may result in papillary conjunctivitis, punctate inferior corneal erosions, and marginal keratitis.

Differential diagnostics

• Dry eye may have similar symptoms, but unlike blepharitis, eye irritation rarely occurs in the morning and usually appears later in the day.
• Infiltrative growth of eyelid tumors should be suspected in patients with asymmetric or unilateral chronic blepharitis, especially in combination with madarosis.

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Diagnosis of blepharitis

The diagnosis of blepharitis is usually made by slit-lamp examination (biomicroscopy). Chronic blepharitis that does not respond to treatment requires a biopsy to rule out eyelid tumors that may be causing the disease.

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Treatment of blepharitis

Patients should be aware that stabilization of the process is usually possible despite inconstant, sometimes tiring treatment. In chronic cases, several weeks of intensive treatment lead to improvement.

1. Eyelid hygiene consists of daily removal of crusts and accumulated discharge from the eyelash edges with a cotton swab (terry cloth or handkerchief) soaked in a 25% solution of baby shampoo or a weak solution of sodium bicarbonate. Eyelid hygiene with diluted shampoo while washing hair is also useful. Gradually, in case of improvement, such manipulations can be carried out less often, but not stopped, since blepharitis can worsen again.
2. An antibiotic ointment, such as fucidin or chloramphenicol, is used to treat acute folliculitis. The ointment is rubbed into the anterior margin of the eyelid with a cotton swab or a clean finger. In chronic cases, this treatment may not be effective.
3. Mild topical steroids such as fluorometholone, used 4 times daily for short periods, are useful in cases of secondary papillary conjunctivitis or marginal keratitis.
4. Tear substitutes are used in secondary tear film instability. If this aspect of the disease is not investigated, the treatment will be incomplete, and the symptoms of the disease will persist.

For acute ulcerative blepharitis, an antibiotic ointment is prescribed (e.g., bacitracin/polymyxin B or 0.3% gentamicin 4 times a day for 7-10 days). Acute viral ulcerative blepharitis is treated with systemic antiviral agents (e.g., for herpes simplex, acyclovir 400 mg 3 times a day for 7 days; for herpes zoster, acyclovir 800 mg 5 times a day for 7 days).

Treatment of acute nonulcer blepharitis begins with removal of the irritating factor (eg, friction) or substance (eg, new eye drops). Cold compresses on closed eyelids may speed recovery. If swelling persists for more than 24 hours, topical glucocorticoids (eg, fluorometholone ophthalmic ointment 3 times daily for 7 days) may be used.

Primary treatment for both seborrheic blepharitis and meibomian dysfunction is directed against the development of secondary "dry" keratoconjunctivitis. In most patients, tear substitutes and occlusive devices are effective. If necessary, additional treatment for seborrheic blepharitis includes gentle cleansing of the lid margin twice daily with a cotton swab soaked in a dilute solution of baby shampoo (2-3 drops in 1/2 cup of warm water). An antibiotic ointment (bacitracin/polymyxin B or 10% sulfacetamide twice daily for 3 months) may be added when lid hygiene alone is insufficient. If necessary, additional treatment for meibomian dysfunction includes warm, wet compresses to melt waxy plugs and sometimes lid massage to loosen secretions. Tetracycline 1000 mg daily and 25-500 mg daily after clinical improvement after 2-4 weeks or doxycycline 100 mg twice daily tapered to 50 mg daily by 2-4 weeks of treatment may also be effective. Isotretinoin may also be used for meibomian gland dysfunction but may cause a dry eye sensation.

Treatment of blepharitis is usually long-term, improvement occurs very slowly (it is necessary to eliminate the cause of the disease). Correction of refractive anomalies, elimination of unfavorable endogenous and exogenous factors (focal infection, dust, chemical vapors), examination and treatment by a gastroenterologist, endocrinologist, dermatologist and allergist are carried out.

What is the prognosis for blepharitis?

With continuous treatment, the prognosis is favorable, although the clinical course of the disease is protracted, and frequent relapses may occur. The most difficult to cure is staphylococcal blepharitis, which can lead to the appearance of styes, chalazions, deformations of the edges of the eyelids, trichiasis, chronic conjunctivitis and keratitis.

Most acute blepharitis responds positively to treatment, but relapse and/or chronic blepharitis may develop. Chronic blepharitis is a sluggish, recurrent, and treatment-resistant disease. Exacerbations cause discomfort and cosmetic defects, but usually no corneal scarring or vision loss.