Ophthalmology · Eyelid Disorders
The facts most likely to be tested
Blepharitis is a chronic inflammatory condition of the eyelid margins characterized by erythema, edema, and crusting at the base of the eyelashes.
The anterior form of blepharitis is most commonly associated with Staphylococcus aureus infection or seborrheic dermatitis.
The posterior form of blepharitis is caused by meibomian gland dysfunction, leading to altered tear film composition and evaporative dry eye.
Patients typically present with bilateral symptoms of burning, grittiness, foreign body sensation, and photophobia that are worse upon awakening.
Slit-lamp examination reveals scurf (flaky debris) or collarettes (fibrinous scales) around the eyelash follicles in anterior blepharitis.
The first-line treatment for all forms of blepharitis is eyelid hygiene, including warm compresses, eyelid scrubs with diluted baby shampoo, and mechanical removal of debris.
Refractory cases or those with significant ocular surface involvement require topical antibiotics (e.g., erythromycin or bacitracin ointment) or oral tetracyclines (e.g., doxycycline) for their anti-inflammatory properties.
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A 45-year-old female presents to the clinic complaining of persistent bilateral eye irritation and a gritty sensation for the past three months. She reports that her symptoms are significantly worse in the morning and improve slightly throughout the day. Physical examination reveals erythema of the eyelid margins and the presence of collarettes at the base of the eyelashes. The conjunctiva is mildly injected, but the visual acuity is 20/20 bilaterally. There is no evidence of corneal ulceration or discharge.
What is the most appropriate initial management for this patient?
Eyelid hygiene with warm compresses and eyelid scrubs
The patient's presentation of bilateral eyelid margin inflammation with collarettes is classic for anterior blepharitis, which is primarily managed with conservative eyelid hygiene measures.
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High yield triage
Etiology / Epidemiology
Common chronic inflammation of eyelid margins. Associated with seborrheic dermatitis and rosacea.
Clinical Manifestations
Bilateral burning, irritation, and crusting of eyelid margins. Collarette formation is pathognomonic.
Diagnosis
Primarily clinical diagnosis. Slit-lamp exam reveals scurf and debris.
Treatment
First-line is eyelid hygiene (warm compresses + baby shampoo). Avoid contact lenses during flares.
Prognosis
Chronic, relapsing condition. Keratitis is the primary sight-threatening complication.
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Epidemiology & Etiology
Affects all ages, often chronic. Frequently linked to seborrheic dermatitis or staphylococcal infection. Patients often present with concurrent meibomian gland dysfunction.
Pertinent Anatomy
Involves the anterior or posterior eyelid margin. Anterior blepharitis affects the eyelash follicles, while posterior involves the meibomian glands.
Pathophysiology
Anterior form is typically staphylococcal or seborrheic. Posterior form results from meibomian gland obstruction, leading to altered tear film composition and evaporative dry eye.
Clinical Manifestations
Patients report burning, itching, and a foreign body sensation. Examination shows erythematous lid margins and collarettes (scales at lash base). Red flags include vision loss or severe pain, which suggest corneal ulceration.
Diagnosis
Diagnosis is clinical. Slit-lamp examination is the gold standard to visualize scurf, debris, and meibomian gland plugging. No specific laboratory thresholds exist.
Treatment
Primary management is eyelid hygiene with warm compresses and diluted baby shampoo. If refractory, use topical azithromycin or erythromycin ointment. Avoid topical steroids unless managed by ophthalmology due to risk of glaucoma or cataracts.
Prognosis
Condition is chronic and requires long-term maintenance. Keratitis and conjunctivitis are common complications. Monitor for corneal ulceration if symptoms persist.
Differential Diagnosis
Conjunctivitis: diffuse injection rather than lid margin crusting
Hordeolum: localized, painful, tender nodule
Chalazion: painless, firm, non-tender nodule
Seborrheic dermatitis: associated scalp/facial scaling
Squamous cell carcinoma: persistent, unilateral, non-healing ulcer