The ratings of importance to the care process (A-C) and the ratings for strength of evidence (I-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 (American Academy of Ophthalmology Preferred Practice Patterns Committee, 2005; American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel, 2007). [A:III]
Patient History
Questions about the following elements of the patient history may elicit helpful information:
- Symptoms and signs: [A:III] (e.g., redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, contact lens intolerance, photophobia, increased frequency of blinking)
- Time of day when symptoms are worse [A:III]
- Duration of symptoms [A:III]
- Unilateral or bilateral presentation [A:III]
- Exacerbating conditions: [A:III] (e.g., smoke, allergens, wind, contact lenses, low humidity, retinoids, diet and alcohol consumption, eye makeup)
- Symptoms and signs related to systemic diseases: [A:III] (e.g., rosacea, allergy)
- Current and previous systemic and topical medications: [A:III] (e.g., antihistamines or drugs with anticholinergic effects, or drugs used in the past that might have an effect on the ocular surface [e.g., isotretinoin])
- Recent exposure to an infected individual: [C:III] (e.g., pediculosis palpebrarum [Pthirus pubis])
The ocular history may take into account details about previous eyelid and ophthalmic surgery and local trauma, including mechanical, thermal, chemical, and radiation injury. A history of cosmetic blepharoplasty is important to obtain because it can make evaporative dry eye worse. A history of styes and/or chalazia is common.
The medical history may also include information about dermatological diseases such as rosacea, atopic disease, and herpes zoster ophthalmicus.
Examination
Examination of the eye and adnexa includes measurement of visual acuity, [A:III] an external examination, [A:III] slit-lamp biomicroscopy, [A:III] and measurement of intraocular pressure. [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 (everting eyelids) [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 chalazia that do not respond well to therapy (Gilberg & Tse, 1992). [A:II] Before obtaining a biopsy for suspected sebaceous gland carcinoma, consultation with the pathologist is recommended [A:III] to discuss the potential need for frozen sections and mapping of the conjunctiva to search for pagetoid spread.
Treatment
There is insufficient evidence to make definitive recommendations for the treatment of blepharitis (Miller et al., 2005) and the patient must understand that a cure is not possible in most cases. Treatments that are helpful include the following:
- Warm compresses
- Eyelid hygiene
- Antibiotics (topical and/or systemic)
- Topical anti-inflammatory agents (e.g., corticosteroids, cyclosporine)
An initial step in treating patients with blepharitis is to recommend warm compresses and eyelid hygiene (Key, 1996). [A:III] Patients should be advised that warm compress and eyelid hygiene treatment, if effective, may be required long term, because the symptoms often recur if treatment is discontinued.[A:III]
The frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment.[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] Alternatively, oral erythromycin (250 mg to 500 mg daily) or azithromycin (250 mg to 500 mg, one to three times a week) can be used.
A brief course of topical corticosteroids may be helpful for eyelid or ocular surface inflammation such as severe conjunctival injection, marginal keratitis, or phlyctenules. 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]
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 advised to return to their ophthalmologist if their condition worsens. [A:III] Visit intervals for patients are dictated by the severity of symptoms and signs, the current therapy, and comorbid factors, such as glaucoma, in patients who have been 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
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, defined as most important
Level B, defined as moderately important
Level C, defined as 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 (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
