The ratings of importance to the care process (A, B, C) and the ratings for strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field.
Diagnosis
The initial evaluation of a patient with symptoms and signs suggestive of blepharitis should include the relevant aspects of the comprehensive medical eye evaluation. [A:III]
Patient History
Questions about the following elements of the patient history may elicit helpful information:
- Symptoms and signs [A:III]
- Duration of symptoms [A:III]
- Unilateral or bilateral presentation [A:III]
- Exacerbating conditions [A:III]
- Symptoms related to systemic diseases [A:III]
- Current and previous systemic and topical medications [A:III]
- Recent exposure to an infected individual [C:III]
The ocular history may take into account details about previous eyelid and ophthalmic surgery and local trauma, including radiation and chemical trauma.
The medical history may take into account information about dermatological diseases such as acne, rosacea, and eczema, and about medications such as isotretinoin.
Examination
The physical examination includes measurement of visual acuity, [A:III] an external examination, [A:III] and slit-lamp biomicroscopy. [A:III] The external examination should be performed in a well-lighted room with particular attention to the following:
- Skin [A:III]
- Eyelids [A:III]
The slit-lamp biomicroscopy should include evaluation of the following:
- Tear film [A:III]
- Anterior eyelid margin [A:III]
- Eyelashes [A:III]
- Posterior eyelid margin [A:III]
- Tarsal conjunctiva [A:III]
- Bulbar conjunctiva [A:III]
- Cornea [A:III]
Diagnostic Tests
A biopsy of the eyelid may be indicated to exclude the possibility of carcinoma in cases of marked asymmetry, resistance to therapy, or unifocal recurrent chalazion that do not respond well to therapy. [A:II] Consultation with the pathologist is recommended prior to obtaining a biopsy for suspected sebaceous gland carcinoma. [A:III]
Treatment
There is insufficient evidence to make definitive treatment recommendations for blepharitis. Treatments that are helpful include the following:
- Warm compresses
- Eyelid hygiene
- Antibiotics
- Topical corticosteroids
Patients should be advised that eyelid hygiene may be required for life, and that symptoms may recur if treatment is discontinued. [A:III]
For patients with staphylococcal blepharitis, a topical antibiotic such as bacitracin or erythromycin can be prescribed and applied on the eyelids one or more times daily or at bedtime for one or more weeks. The frequency and duration of treatment should be guided by the severity of the blepharitis. [A:III]
For patients with meibomian gland dysfunction (MGD), whose chronic symptoms and signs are not adequately controlled with eyelid hygiene, oral tetracyclines can be prescribed. [A:III] A brief course of topical corticosteroids may be helpful for eyelid or ocular surface inflammation such as severe conjunctival injection, marginal keratitis, or phlyctenules. If used, the minimal effective dose of corticosteroid should be utilized and long-term corticosteroid therapy should be avoided if possible. [A:III] Patients should be informed of the potential adverse effects of corticosteroid use, including the risk for developing increased intraocular pressure and cataract. [A:III] Guidelines for maintenance therapy should be discussed. [A:III]
Patients with atypical eyelid-margin inflammation or disease not responsive to medical therapy should be carefully re-evaluated. [A:III]
Follow-up
Patients with mild blepharitis should be informed to return to their ophthalmologist if their condition worsens. [A:III] Visit intervals for patients with severe disease are dictated by the severity of symptoms and signs, the current therapy, and comorbid factors, such as glaucoma, in patients treated with corticosteroids. The follow-up visit should consist of an interval history, measurement of visual acuity, external examination, and slit-lamp biomicroscopy. [A:III] If corticosteroid therapy is prescribed, patients should be re-evaluated within a few weeks to determine the response to therapy, measure intraocular pressure, and assess treatment compliance. [A:III]
Provider and Setting
The diagnosis and management of blepharitis requires broad medical skills and experience. Patients with blepharitis who are evaluated by non-ophthalmologist health care providers should be promptly referred to an ophthalmologist if any of the following occurs: [A:III]
- Visual loss
- Moderate or severe pain
- Severe or chronic redness
- Corneal involvement
- Recurrent episodes
- Lack of response to therapy
Counseling/Referral
One of the most important aspects of caring for patients with blepharitis is educating them about the chronicity and recurrence of the disease process. [A:III] Patients should be informed that symptoms can frequently be improved but are rarely eliminated. [A:III]
Definitions:
Ratings of importance to care process
Level A, most important
Level B, moderately important
Level C, relevant but not critical
Ratings of strength of evidence
- Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization
- Expert opinion (e.g., Preferred Practice Pattern panel consensus)
