History

Fact Explanation
Itching of the eye lid Blepahritis is Inflammation of the palpebra and the edge of the palpebra[1].Chronic blepharitis is a common problem.[5]It usually affect both eyes.[3] Itching is a result of inflammation, usually present chronic itching.[2] Symptoms of blepharitis may be intermittent.[4] Symptoms are worse in the morning[3].
Sore eyes This is a result of chronic inflammation. Symptoms are worse in the morning[3]
Pain in eyes This is in severe disease when cornela corneal epithelium is affected as a complication (Blepharokeratitis).[3]
Foreign body sensation in eyes. This is due to accumulation of squamous debris.This symptom worse in the morning.[3]
History of Lump in the eye lids The patient may present with a chalazion or stye, which are much more common in patients with blepharitis, and these may be recurrent[4]
Contact lens intolerance Patients with blepharitis often complains of contact lense intolerance, may be due to inflamed eye lids. [6]
photo phobia This occur in sever cases only. Chronic inflammation in eye lids may cause this symptom, and it is worse in the morning[7]
References
  1. BEZDETKO P.A., SERGIENKO N, DYOMIN Y, et al. Successful treatment of blepharitis with bibrocathol (Posiformin® 2 %). Graefe's Archive for Clinical and Experimental Ophthalmology[online] Springerlink.com. April 2012,vol. 250(12),1869-1875.[viewed 8th may 2014]. Available from: DOI 10.1007/s00417-012-2001-0
  2. Blepharitis and Meibomitis. In: TIERNEY L.M., SAINT S, WHOOLEY M.A. CURRENT Essentials of Medicine, 4th ed. New York, McGraw Hill Professional; 2010. pp 509-512
  3. The eyelids. In:JAMES B, CHEW C, BRON A. Lecture Notes on Ophthalmology. London:Blackwell Publishing,2003, pp 49-58
  4. Eyelid, orbital, and lacrimal disorders. In: KHAW P.T. ABC of Eyes. London: BMJ Books, 2004, pp 21-28
  5. SEAL D.V, WRIGHT P, FICKER L, HAGAN K, TROSKI M, MENDAY P. Placebo controlled trial of fusidic acid gel and oxytetracycline for recurrent blepharitis and rosacea. British Journal of Ophthalmology[online] BMJ. January 1995. Vol. 79(1) 42-45 [.[viewed 8th may 2014]. Available from: www.ncbi.nlm.nih.gov/pmc/articles/PMC505018
  6. LINDSLEY K, MATSUMURA S, HATEF E, AKPEK E.K. Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews.[online] JohnWiley & Sons, Ltd.February 2012. Vol. 5. 10-20 .[viewed 8th may 2014]. Available from: doi: 10.1002/14651858.CD005556.pub2.
  7. BOTO-DE-LOS-BUEIS A, DEL HIERRO ZARZUELO A, GARCíA PEREA A, DE PABLOS M, PASTORA N, NOVAL S. Staphylococcus aureus Blepharitis Associated with Multiple Corneal Stromal Microabscess, Stromal Edema, and Uveitis. Ocul Immunol Inflamm [online] 2014 Jan 10 [viewed 12 May 2014] Available from: doi:10.3109/09273948.2013.870214

Examination

Fact Explanation
Inflamed eye lid margins Due to chronic inflammation eyelids become inflamed and injected.[1]In addition, in staphylococal blepharitis there is nodular inflammatory leisons in eye lids[2]. Blepharitis is catagorized into anterior and posterior blepharitis. Anterior blepharitis incleudes an infectious and inflammatory condition of the external lamella of the eyelids and lashes, and Posterior blepharitis is mainly related to dysfunction of the meibomian glands, which is also known as meibomian gland disease(MGD)The meibomian secretions become thickened and lead to block the glands orifices[3]In staphylococal blepharitis toxins produced by certain strains of S. aureus or S. epidermis may be a cause of irritation leading to inflammation. Lid inflammation more in staphylococcal than seborrheic blepharitis.[2]
Crusts round the lid margins This condition causes squamous debris,debris in the form of a rosette around the eyelash, the base of which may also be ulcerated, a sign of staphylococcal infection[1]. staphylococcal blepharitis gives dry scaling whereas seborrheic blepharitis with more oily or greasy scaling.[2]
Obstruction and plugging of the meibomian ducts This is due to abnormally thickened secretions. This is more prominent in meibomian gland dysfunction(MGD) type.Meibomian gland dysfunction is defined as “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease.”MGD affects primarily the oil glands located on the posterior lid and therefore it is included as a subset of posterior blepharitis.Some patients with seborrheic blepharitis also exhibit characteristics of MGD[2]
signs of associated conditions Blepharitis is strongly associated with seborrhoeic dermatitis, and acne rosacea. In rosacea there is hyperaemia and telangiectasia of the facial skin and a rhinophima (a bulbous irregular swelling of the nose with hypertrophy of the sebaceous glands). Seborrhoeic dermatitis most often seen on the face and/or scalp as ill-defined erythematous patches associated with fine (pityriasiform) scaling, involving scalp, anterior hairline eyebrows, glabella region of the forehead, nasal alar creases, melolabial folds,ears central chest, and genital region[4]
Reduction of number of eye lashes This is due eye lid inflammation and falling of eye lashes.[1]
References
  1. The eyelids. In:JAMES B, CHEW C, BRON A. Lecture Notes on Ophthalmology. London:Blackwell Publishing,2003, pp 49-58
  2. LINDSLEY K, MATSUMURA S, HATEF E, AKPEK E.K. Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews.[online] JohnWiley & Sons, Ltd. February 2012. Vol. 5. 10-20 .[viewed 8th may 2014]. Available from: doi: 10.1002/14651858.CD005556.pub2.
  3. LUCHS J. Azithromycin in DuraSite for the treatment of blepharitis. Clinical Ophthalmology.[online] Dovepress.june 2010, vol. 4. 681-688. .[viewed 8th may 2014]. Available from: www.ncbi.nlm.nih.gov/pubmed/20689782
  4. DEL ROSSO J.Q. Adult seborrheic dermatitis: a status report on practical topical management. The Journal of Clinical and Aesthetic Dermatology.[online]Matrix Medical Communications. november 2011, vol. 4(5),32-38. .[viewed 8th may 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100109/

Differential Diagnoses

Fact Explanation
Chalazion This is a common painless condition in which an obstructed meibomian gland causes a granuloma within the tarsal plate. Symptoms are of an unsightly lid swelling which usually resolves within 6 months. No itching or scaling like in blepharitis.[1]
stye A stye (external hordeolum) is a painful abscess of an eyelash follicle. Swelling is localized than blepharitis. And there is no itching, scaling of the eye lid.[1]
Phthiriasis palpebrarum Phthiriasis palpebrarum (PP) is an eyelid infestation caused by phthirus pubis or crab lice. main symptom is itching of eyelids.Examination findings sre similar to exfoliative lesions and color changes in eyelids and to excretions over eyelashes. Careful observation needed to reveal lice and translucent nits. Slit-lamp examination will be helpful to find lice.[2]
Molluscum contagiosum This umbilicated lesion found on the lid margin is caused by the pox virus. It causes irritation of the eye. The eye is red and small elevations of lymphoid tissue (follicles) are found on the tarsal conjunctiva. But there is no itching, scaling, or lid edema as in blepharitis.[1]
Conjunctivitis In conjunctivitis there is inflamed,injected conjunctiva, red eye, and excessive tearing from the aye. in bacterial conjunctivitis there may also purulent discharge than other types. there is no eye lid swelling, scalling oe meibomian glannd dysfunction like in blepharitis.[1]
Dermatitis Usually present with pruritus, are erythematous, exudative skin leisons of the antecubital and/or popliteal skin, eyelids, There is also involment of corners of the mouth, neck, outer canthi, or behind the ears, face and extensors surfaces. There are physcial findings of the blepaharitis as well, since blepharitis is a associated condition.[1]
Roscea Blepaharitis is a associated condition in roscea, In roscea there is also hyperaemia and telangiectasia of the facial skin and a rhinophima (swelling of the nose[1]
Keratitis Patients with keratitis present with rapid onset of pain, photophobia, and decreased vision. patient may also give a history of contact lens use, trauma to eye. on examination there wirll be ulceration of the coneal epithelium Folds in the Descemet membrane, Upper eyelid edema. But there is no itching, scalling of the eye lid like in blepaharitis.[1]
References
  1. JAMES B, CHEW C, BRON A. Lecture Notes on Ophthalmology. London:Blackwell Publishing,2003
  2. TURGUT B, KURT J, CATAK O, DEMIR T. Phthriasis palpebrarum mimicking lid eczema and blepharitis. Journal of Ophthalmology. [online]Hindawi. October 2009. Vol. 2009. 1-3. .[viewed 8th may 2014]. Available from: doi: :10.1155/2009/803951

Investigations - for Diagnosis

Fact Explanation
Lid cultures Cultures form the lid margin will be helpful to diagnose to specific stains of organism that infects and also to differentiate seborrheic blepharitis from staphylococcal blepharitis in difficult cases. [1]
Slit lamp examination. Help to identify demodex infestation in the eyelid[1]
References
  1. BOTO-DE-LOS-BUEIS A, DEL HIERRO ZARZUELO A, GARCíA PEREA A, DE PABLOS M, PASTORA N, NOVAL S. Staphylococcus aureus Blepharitis Associated with Multiple Corneal Stromal Microabscess, Stromal Edema, and Uveitis. Ocul Immunol Inflamm [online] 2014 Jan 10 [viewed 12 May 2014] Available from: doi:10.3109/09273948.2013.870214

Management - General Measures

Fact Explanation
Eye lid hygiene Initial treatment is eyelid hygiene, it has three components,warm compresses, eyelid massage, and eyelid scrub.Warm compresses should be done for at least 5 minutes, followed by lid massage at least once daily. The warm compresses help to melt the altered secretions of the meibomian glands. Eyelidmassage, this is compressing the eye lid against the eye balll, it helps to milk excess secretions from the meibomian glands. By eye lid scrub, eyelid margin is washed mechanically and clean the gland orifices which consist of gently scrubbing the eyelids with a wet washcloth. This is performed after the warm compresses [1]
Artificial tears. The tear film in patients with blepharitis is abnormal, and artificial tears may provide considerable relief of symptoms[2]
References
  1. LINDSLEY K, MATSUMURA S, HATEF E, AKPEK E.K. Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews.[online] JohnWiley & Sons, Ltd.February 2012. Vol. 5. 10-20 .[viewed 8th may 2014]. Available from: doi: 10.1002/14651858.CD005556.pub2.
  2. Eyelid, orbital, and lacrimal disorders. In: KHAW P.T. ABC of Eyes. London: BMJ Books, 2004, pp 21-28

Management - Specific Treatments

Fact Explanation
Topical antibioics Topical antibiotics are used to treat both Staphylococcal and seborrheic blepharitis, preferably in ointment form, [3] They are applied usually at bed time[1] It is smeared on the lid margin to reduce the staphylococci flora in the lid.This treatment is required for several month to have a reasonable response[2]Ointment is applied after lid hygiene are done. Treatment regimen would be once or twice daily depending on the severity of the inflammation[3] Commonly used antibiotics are fusidic acid gel.[4],erythromycin and bacitracin. Antibiotic therapy may be discontinued in two to eight weeks or once symptoms resolve.But in some patients with severe disease . treatment will require for long duration to keep the patient symptom free.[3]
Topical antiseptics Bibrocathol is a antiseptic drug for the treatment of acute eyelid diseases.Eye ointments containing 2 or 5 % bibrocathol are used to treat bleparitis[5]
Topical steroids. Topical steroids may improve an anterior blepharitis but frequent use is best avoided[4] All forms of blepharitis may benefit from a course of treatment with topical corticosteroid drops to decrease inflammation in an acute exacerbation. Should applying drops several times daily, tapered to discontinuation over one to three weeks as it have significant adverse effects over the long-term such as increased intraocular pressure (IOP), posterior subcapsular cataract formation, and superinfection. For this reason they are not recommended for long-term use[3]
Oral antibiotics In patients with posterior blepharitis oral tetracycline or doxycyclinemay is effective[3]
References
  1. Blepharitis and Meibomitis. In: TIERNEY L.M., SAINT S, WHOOLEY M.A. CURRENT Essentials of Medicine, 4th ed. New York, McGraw Hill Professional; 2010. pp 509-512
  2. Eyelid, orbital, and lacrimal disorders. In: KHAW P.T. ABC of Eyes. London: BMJ Books, 2004, pp 21-28
  3. LINDSLEY K, MATSUMURA S, HATEF E, AKPEK E.K. Interventions for chronic blepharitis. Cochrane Database of Systematic Reviews.[online] JohnWiley & Sons, Ltd.February 2012. Vol. 5. 10-20 .[viewed 8th may 2014]. Available from: doi: 10.1002/14651858.CD005556.pub2.
  4. The eyelids. In:JAMES B, CHEW C, BRON A. Lecture Notes on Ophthalmology. London:Blackwell Publishing,2003, pp 49-58
  5. BEZDETKO P.A., SERGIENKO N, DYOMIN Y, et al. Successful treatment of blepharitis with bibrocathol (Posiformin® 2 %). Graefe's Archive for Clinical and Experimental Ophthalmology[online] Springerlink.com. April 2012,vol. 250(12),1869-1875.[viewed 8th may 2014]. Available from: DOI 10.1007/s00417-012-2001-0