Blepharitis eyelid: scaly, demodectic, allergic, seborrhoeic, ulcerative

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

Diagnosis is based on history and examination data. In acute ulcerative blepharitis, local antibiotics are usually prescribed, as well as systemic antiviral agents. With acute non-ulcerative blepharitis, the administration of local glucocorticoids is possible. Chronic disease requires eyelid hygiene (seborrheic blepharitis), the appointment of moist compresses (meibomian gland dysfunction) and tear replacements (seborrheic blepharitis, meibomian gland dysfunction).

[1], [2], [3], [4], [5], [6], [7], [8], [9]

What causes blepharitis?

Distinguish depending on the etiology or infectious (primary), inflammatory, or non-inflammatory blepharitis. Infectious blepharitis is more often caused by bacterial (Staphylococcus aureus, S. Epidermidis, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella lacunata), probably by viruses (herpes simplex virus, herpes zoster virus, molluscum contagiosum), fungi (Pityrosporum ovale and R. Orbiculare), arthropods (mites - Demodex folliculorum humanis and D. Brevis, lice - Phthirus pubis). Noninfectious blepharitis often develops with seborrhea, pinkheads, eczema. Blepharitis is much more often diagnosed in pensioners and in immunodeficiency of different etiology (HIV, immunosuppressive chemotherapy).

Blepharitis can be acute (ulcerative or non-ulcerative) or chronic (seborrheic blepharitis or meibomian gland dysfunction). Acute ulcerative blepharitis is usually caused by a bacterial infection (usually staphylococcal) of the edge of the eyelid at the point of eyelash withdrawal, involving the follicles of the eyelashes and the meibomian glands. It can also be caused by viruses (for example, herpes simplex virus or herpes zoster). Acute non-ulcerous blepharitis is usually caused by an allergic reaction involving the same area (eg, atopic blepharodermatitis, seasonal allergic blepharoconjunctivitis, contact dermatovenopharyconjunctivitis).

Chronic blepharitis is a noninfectious inflammation of unknown etiology. Seborrheic blepharitis is often combined with seborrheic dermatitis of the face and scalp. Often there is a secondary bacterial colonization on scales that are formed on the edges of the eyelids.

Meibomian glands of the eyelids produce lipids (meibum), which stabilize the tear film, forming a lipid layer anterior to the aqueous layer, reducing its evaporation. With the dysfunction of meibomian glands, the lipid composition is abnormal, the ducts and orifices of the glands are filled with waxy eyes, in most patients there is increased evaporation of tears and "dry" keratoconjunctivitis. The disease is often combined with rosacea and relapsing barley or halazion in the anamnesis.

Secondary blepharitis - from lacrimal passages, sinuses of the nose, conjunctiva. With infectious blepharitis, pathogens are most often staphylococci, streptococci, viruses of simple and herpes zoster, molluscum contagiosum, pathogenic fungi, possibly with arthropods (mites and lice). Noninfectious blepharitis occurs with seborrhea, rosacea, eczema.

The disease blepharitis affects mainly children and young people.

Blepharitis begins in early childhood, often lasts for many years. The emergence of blepharitis contributes to adverse sanitary and hygienic conditions, work and poorly ventilated, dusty and smoky rooms; In rooms where the air is contaminated with chemicals. Great importance in the emergence of blepharitis has a general state of the body. Blepharitis occurs more often with seborrhea, eczematous lesions of the skin or inclination to them, anemia, avitaminosis, scrofula, with chronic diseases of the gastrointestinal tract, accompanied by stagnation in the large circulation. Often, the disease is 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 errors, especially hypermetropia and astigmatism, as well as age-related accommodation (presbyopia) that are not timely rectified by the corresponding glasses.

To the development of blepharitis predisposes a delicate tender skin, which is more common in blonde people.

Classification of chronic blepharitis

1. Front

1. staphylococcal
2. seborrheic
3. mixed

2. Rear

1. Meibomian seborrheic
2. meibomite

3. Mixed (front and rear)

[10], [11], [12], [13], [14], [15], [16]

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.

With acute ulcerative blepharitis, small pustules form in the lashes of the eyelashes, which eventually break up, forming superficial marginal ulcers. Densely adjoining crusts leave a bleeding surface after removal. During sleep, the eyelids are glued together with a dried discharge. Recurrent ulcerative blepharitis can cause loss of eyelashes and scarring of the eyelids.

With acute non-ulcerous blepharitis, the edges of the eyelids become swollen and reddened; eyelashes can be covered with crusts of dried serous fluid.

With seborrheic blepharitis on the edges of the eyelids, sebaceous, easily separated scales are formed. With dysfunction of meibomian glands, the examination reveals enlarged, compacted orifices of glands, of which a waxy, dense, yellowish secret is prominent when pressed. Most patients with seborrheic blepharitis and meibomian gland dysfunction have a secondary "dry" keratoconjunctivitis, which is characterized by the sensation of foreign body, sand, strain and fatigue of the eyes and blurring of vision with prolonged visual load.

Blepharitis: Species

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

[17], [18], [19], [20], [21]

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 edge of the eyelid and eyelashes that resemble dandruff. The patient complains of burning, itching, eyelid heaviness, rapid fatigue of the eyes. The edges of the eyelids are reddened, thickened. Symptoms of the progression of the inflammatory process: smoothing of the anterior and posterior ribs of the free edge of the eyelid and a violation of 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 usually has a two-sided nature, as a result of this, with a long-existing unilateral pathology, it is necessary to exclude the tumor lesion of the eyelid.

With scaly blepharitis, daily applications with alkaline solutions for softening the scales with further cleansing of the eyelid edges with a mixture of alcohol with ether or a solution of the brilliant green are required. This procedure is carried out slightly with a wet swab of cotton wool so that alcohol does not get into the conjunctival cavity. In addition to all this, 1-2 times a day at the edge of the eyelids, an ocular 0.5% hydrocortisone ointment is applied (course up to 2-3 weeks). A 0.25% solution of zinc sulfate is instilled in the conjunctival cavity.

Ulcerative (staphylococcal) blepharitis

Ulcerous (staphylococcal) blepharitis is characterized by the formation of purulent crusts, clumping of eyelashes, ulceration of the skin of the eyelid margins. With this form of blepharitis, drawing into the pathological process of hair follicles (folliculitis) causes shortening and brittleness of the eyelashes, scarring of the edge of the eyelid, which sometimes leads to improper growth, saddle or loss of eyelashes. In difficult cases, a bacteriological examination of the smear from the surface of the ulcer is carried out.

With ulcerative blepharitis, the cleansing of the eyelid edges is carried out similarly, as with scaly form of the disease. Also, with bacterial infection, 2-3 times a day, ointments are applied to the edges of the eyelids, under the action of which the crusts soften, after that they are easier to remove; It is possible to make applications of gauze strips moistened with antibiotic solution (0.3% solution of gentamicin), up to 3 times a day for 4 days. Ointment with antibiotic (tetracycline, erythromycin) is selected according to the results of bacteriological research, eye ointments containing antibiotics and corticosteroids ("Dexa-Gentamycin", "Maxitrol") are often used. Possibly topical application, 0.25% zinc sulfate solution, 0.3% cypromed solution.

Posterior (marginal) blepharitis, or meibomian gland dysfunction

The posterior (marginal) blepharitis, or meibomian gland dysfunction, is characterized by a local or diffuse inflammatory response: reddening and thickening of the eyelid edges, the formation of telangiectasias in the blocked meibomian gland openings, their hypo- or hypersecretion, the accumulation of a yellowish-gray foamy secretion in the outer corners of the eye gap and the posterior rib of the free edge of the eyelids, the hyperemia of the palpebral conjunctiva, the violation of the pre-corneal film. When squeezing the edge of the century between the finger and a glass rod of meibomian glands, a foamy secret emerges.

With dysfunction of meibomian glands, daily treatment of eyelid edges is required according to the previously described procedure, use of alcohol with ether, use of warm alkaline lotions (2% sodium hydrogen carbonate solution) for 10 min. The eyelid massage is carried out with a glass rod after a single instillation of a 0.5% solution of dicaine. It is advisable to lubricate the edges of the eyelids with "Dexa-Gentamycin" or "Maxitrol", and in the case of a steep eye 0.5% hydrocortisone ointment (up to 2 weeks).

Demodectic blepharitis

Demodectic blepharitis is manifested by the reddening and thickening of the edges of the eyelids, the presence of scales, crusts, white clutches on the eyelashes. The tick settles in the lumens of the meibomian glands, the ciliary follicles. The main complaint of patients - itching in the eyelids. If you suspect a demodectic nature of blepharitis with a diagnostic purpose, remove five eyelashes from each century and stack them on a slide. The diagnosis of demodectic blepharitis is confirmed by the detection of larvae around the root of the eyelash and six or more mobile ticks. Identification of a smaller number of individuals indicates only carriage (normal among healthy individuals, it reaches 80%).

After cleansing the edges of the eyelids with a mixture of alcohol and ether, the eyelids massage is performed, and then at night the free eyelid margins are abundantly lubricated with neutral ointments (Vaseline, vidisik-gel), and with combined bacterial flora they use combined ointments containing an antibiotic and corticosteroid ("Dexa-Gentamicin" , "Maxitrol") a short course. Inside take anti-inflammatory and desensitizing drugs, you can appoint Trichopol.

[22], [23], [24], [25]

Anterior blepharitis

Symptoms of anterior blepharitis: burning, feeling of "sand", moderate photophobia, crusts and reddening of the edges of the eyelids. Usually, by the 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 margin of the eyelid with hard scales, localized mainly at the base of the lashes (clamps);
• Seborrheic blepharitis is characterized by hyperemia and greasy plaque of the anterior margin of the eyelid, ligated eyelashes. Soft scales scattered around the edge of the eyelids;
• pronounced chronic anterior blepharitis, especially staphylococcal, can lead to hypertrophy and scarring of the edge of the eyelid, madarose, trichiasis and polyosis.

Combination with other eye manifestations

• When spreading the infection in the glands of Moll and Zeis, the outer barley may differ.
• In 30-50% of cases, tear film instability is observed.
• Hypersensitivity to staphylococcal exotoxin can lead to papillary conjunctivitis, pinpoint erosions of the cornea in the lower part and marginal keratitis.

Differential diagnostics

• A "dry" eye can have similar signs, but unlike blepharitis, eye irritation rarely occurs in the morning, usually appears later in the day.
• Infiltrative growth of tumors of the eyelids should be suspected in patients with asymmetric or unilateral chronic blepharitis, especially in combination with madarose.

[26], [27], [28], [29], [30], [31]

Diagnosis of blepharitis

The diagnosis of blepharitis is usually established by examination on a slit lamp (biomicroscopy). Chronic blepharitis, which does not respond to treatment, requires a biopsy to exclude eyelid tumors that can stimulate the disease.

[32], [33]

Treatment of blepharitis

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

1. The hygiene of the eyelids consists in the daily removal of the crusts and the accumulated cervical tampon (terry cloth or handkerchief) that has been separated from the ciliated edges, moistened with a 25% solution of baby shampoo or a weak solution of sodium bicarbonate. Also, hygiene of the eyelids is diluted with shampoo during hair washing. Gradually, in the case of improvement, such manipulations can be carried out less often, but not stop, because blepharitis can become aggravated again.
2. An ointment with an antibiotic, for example fucidine or chloramphenicol, is used to treat acute folliculitis. The ointment is rubbed into the front edge of the eyelid with a cotton loaf or a clean finger. In chronic cases this treatment may not be effective.
3. Weak local steroids, for example, fluorometholone, are used 4 times a day for a short time. They are useful in the case of secondary papillary conjunctivitis or marginal keratitis.
4. Tear replacements are used in the secondary instability of tear film. If this aspect of the disease is not investigated, treatment will be incomplete, the symptoms of the disease will persist.

In acute ulcerative blepharitis, an antibiotic is prescribed in the form of an ointment (eg, bacitracin / polymyxin B or 0.3% gentamycin 4 times a day for 7-10 days). Acute viral peptic ulcer blepharitis is treated with systemic antiviral agents (for example, with simple herpes, aciclovir is prescribed 400 mg 3 times a day for 7 days, while shingles, acyclovir 800 mg 5 times a day for 7 days).

Treatment of acute non-ulcerous blepharitis begins with the exclusion of an irritating factor (eg, friction) or a substance (for example, new eye drops). Cold compresses on closed eyelids can accelerate the recovery. If the swelling lasts more than 24 hours, local glucocorticoids (for example, ophthalmic ointment of fluorometholone 3 times a day for 7 days) can be used.

Primary treatment of both seborrheic blepharitis and dysfunction of meibomian glands is directed against the appearance of secondary "dry" keratoconjunctivitis. In most patients, tear replacement and occludor installation are effective. If necessary, additional treatment of seborrhoeic blepharitis includes gentle cleansing of the edge of the eyelid 2 times a day with a cotton swab soaked in a diluted solution of baby shampoo (2-3 drops per 1/2 cup of warm water). An antibiotic may be added as an ointment (bacitracin / polymyxin B or 10% sulfacetamide 2 times a day for 3 months), when hygienic eyelid care is not enough. If necessary, additional treatment for meibomian gland dysfunction includes warm moist compresses to melt the waxy congestion and sometimes massage the eyelids to separate the secretions. It can also be effective tetracycline at 1000 mg per day and 25-500 mg per day after clinical improvement after 2-4 weeks or doxycycline at 100 mg 2 times a day with a dose reduction of up to 50 mg per day by 2-4 weeks treatment. With dysfunction of the meibomian glands, isotretinoin can also be used, but it can lead to a feeling of dryness in the eye.

The treatment of blepharitis is usually prolonged, the improvement is very slow (it is necessary to eliminate the cause of the disease). Correction of abnormalities of refraction, removal of unfavorable endogenous and exogenous factors (focal infection, dust, chemical vapors), examination and treatment with a gastroenterologist, endocrinologist, dermatologist and allergist are performed.

What is the prognosis of blepharitis?

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

Most often with acute blepharitis there is a positive effect of treatment, but there may be a relapse and / or develop chronic blepharitis. Chronic blepharitis is a dull, relapsing and resistant to treatment disease. When exacerbations there are discomfort and cosmetic defects, but usually there is no scarring of the cornea or loss of vision.