Blepharitis Overview and Symptoms

Blepharitis

• Inflammation of eyelid margins, chronic and recurrent
• Anterior, Posterior, or Mixed Lid Margin Disease
• Anterior Blepharitis
  • Associated with bacterial colonization (primarily staphylococcal) or seborrheic dermatitis
  • Symptoms: ocular discomfort, soreness, burning, itching, mild photophobia, blurred vision, intolerance to contact lenses
  • Signs: aqueous tear deficiency, lid margin hyperaemia, swelling, crusting, loss of lashes, marginal keratitis, mild papillary conjunctivitis, and oily/greasy deposits on lid margins if seborrheic.
• Posterior Blepharitis
  • Meibomian gland dysfunction (retention of secretions/blockage)
  • Symptoms: irritation, burning, foreign body sensation, worse in mornings
  • Signs: watering, photophobia, erythema, telangiectasia, foamy meibomian gland secretions
• Mixed Lid Margin Disease: both anterior and posterior lid margins affected
• Predisposing conditions: dry eye syndrome (50% of staph bleph, 25-20% of seborrheic bleph), acne rosacea

Complications of Blepharitis

• Epiphora (excess tearing), dry eyes, conjunctivitis, chalazion formation, trichiasis (misdirected eyelashes), ectropian (eyelid turns outwards), entropian (eyelid turns inwards)
• Corneal disease: punctate epithelial erosion, marginal infiltrates, recurrent erosions, marginal ulcers, pannus, keratitis, contact lens intolerance

Treatment

• Lid hygiene (cleaning with cotton buds/flannel with baby shampoo or bicarbonate of soda solutions)
• Warm compresses (twice daily, 10 minutes)
• Topical lubricants for dry eyes
• Topical antibiotics (e.g., chloramphenicol) for infections
• Oral tetracyclines (if lid hygiene isn't effective, especially in those with acne rosacea)
• Topical steroids (severe cases with marginal keratitis complications)

Hordeolum (Stye)

• Localized infection/inflammation of eyelid margin
• External hordeolum: involves eyelash follicle; points toward skin, less painful
• Internal hordeolum: involves meibomian glands; points towards conjunctiva, more painful
• Symptoms: tender inflamed swelling
• Management: warm compresses, removal of infected eyelash (if appropriate), topical antibiotics (if needed)
• Spontaneous resolution possible

Trichiasis

• Trichiasis is characterized by misdirected eyelashes that grow toward the globe of the eye, which can lead to discomfort and potentially serious complications.
• Causes of trichiasis include a variety of factors such as ageing which can cause structural changes in the eyelid, scarring of the posterior lid lamella often due to previous injuries or surgeries, blepharitis (a common inflammatory condition of the eyelids), epiblepharon (a condition where skin folds cause eyelashes to misdirect), herpes zoster (which can cause scarring and eyelid deformities), trachoma (a bacterial infection that can lead to scarring of the eyelids), and ocular cicatrical pemphigoid (a rare autoimmune condition leading to scarring of the conjunctiva and eyelids).
• Signs of trichiasis often include conjunctival injections, indicating inflammation; pain, which can be significant; foreign body sensations experienced by patients due to the irritation from eyelashes; and posterior lamellar scarring that can worsen visual outcomes if not addressed.
• Management involves the removal of misdirected eyelashes through procedures like electrolysis or other methods, in addition to addressing any underlying causes to prevent recurrence.

Entropian

• Entropian is defined as the inversion or rolling inward of the eyelid, which can lead to the eyelashes constantly irritating the cornea.
• There are several types of entropian: involutional entropian, which is age-related; cicatrical entropian caused by scarring of the eyelid due to previous trauma or disease; spasmodic entropian, associated with muscle spasms, and congenital entropian, which is a condition present from birth.
• The primary symptoms include severe discomfort when eyelashes rub against the cornea, potentially leading to corneal abrasions and further complications if left untreated.
• Management options for entropian include conservative methods such as eye taping to temporarily hold the eyelid in a proper position, eyelid taping as a more controlled intervention, and surgical options which may be necessary for permanent correction.

Ectropian

• Ectropian is characterized by the outward rotation of the eyelid away from the eye, leading to exposure of the conjunctiva and other ocular structures.
• Common symptoms experienced by individuals with ectropian include dryness of the eye, irritation especially when exposed to wind and environmental elements, and corneal exposure which may lead to further complications such as keratitis.
• Signs that might be observed during an examination include conjunctival hyperemia, indicating increased blood flow to the conjunctival tissue; corneal exposure, resulting in potential damage to the cornea; and tearing due to reflex responses to irritation.
• The management of ectropian typically involves taping the eyelid to provide temporary relief, surgical interventions to properly reposition the eyelid, and the use of ocular lubricants to address dryness and protect the cornea.

Pre-septal Cellulitis

• Pre-septal cellulitis refers to an infection involving the eyelid and periorbital tissues, primarily affecting the soft tissues in front of the orbital septum.
• This condition is particularly common among children younger than 5 years of age, highlighting the need for vigilant monitoring and early intervention.
• Symptoms typically include acute eyelid erythema (redness), eyelid edema (swelling), and pain, which can markedly decrease quality of life and function.
• Common causes of pre-septal cellulitis include the spread of infections from adjacent sinuses, trauma that may introduce bacteria, or surgical interventions that can predispose to infection.
• Management strategies include systemic antibiotics for general treatment, intravenous (IV) antibiotics in more severe cases that do not respond to oral medications, and CT scans of the orbit and sinuses for cases that do not show improvement to examine for possible complications such as abscess formation.

Orbital Cellulitis

• Orbital cellulitis is a severe condition characterized by the infection of the tissues located behind the orbital septum, posing a risk for serious complications.
• The symptoms may mirror those of pre-septal cellulitis but often present with more rapid progression, which can lead to increased risk of vision loss and other ocular complications.
• Primary causes of orbital cellulitis often include the extension of infection from adjacent sinus structures, emphasizing the importance of addressing sinus infections effectively.
• Management of orbital cellulitis necessitates aggressive treatment approaches, including the initiation of IV antibiotics to effectively combat the infection, and potential surgical intervention may be required to drain abscesses and alleviate any orbital pressure.

Tumors

• Basal cell carcinoma represents the most common form of eyelid cancer, known for its slow-growing nature and local invasion. It typically presents as a non-healing ulcer characterized by a pearly border, which originates from the basal layer of the epidermis. This type of cancer is more prevalent among individuals with lighter skin tones, underscoring the impact of ultraviolet (UV) exposure in its pathogenesis.
• Squamous cell carcinoma, while less common than basal cell carcinoma, is identified as the second most prevalent eyelid cancer. This type of cancer is noted for its aggressive behavior, and it is often associated with significant sun exposure, increasing the risk for outdoor workers and individuals with a history of excessive tanning or sunburns. Importantly, squamous cell carcinoma has the potential to metastasize, making early detection and treatment critical.

Benign Eyelid Lesions

• Benign eyelid lesions include a range of conditions such as cysts of Moll and cysts of Zeiss, as well as molluscum contagiosum, which are viral-induced lesions that can appear on the eyelids.
• These lesions characteristically present as cyst-like bulges around the eyelid margin, which can be more aesthetically concerning than medical concerns for the patients.
• Management of benign eyelid lesions typically involves surgical removal, often performed for cosmetic reasons as these lesions can be unsightly and lead to self-esteem issues for affected individuals.

Thyroid Eye Disease

• Thyroid eye disease, also known as Graves' ophthalmopathy, presents with signs including proptosis (forward displacement of the eye), lid retraction, lid lag (when the upper lid fails to follow the eye movement), irritation of the eyes, and significant corneal dryness.
• This condition is primarily caused by autoimmune responses, particularly in connection with Graves' disease, which leads to inflammation and swelling of the eye muscles and fatty tissue around the eyes.
• Symptoms can range from minor eyelid problems to significant visual loss, particularly if the optic nerve experiences compression due to swelling or expansion of ocular structures.
• The management of thyroid eye disease focuses on treating the underlying autoimmune problem and controlling symptoms. Urgent referral to an ophthalmologist is essential if optic nerve involvement is suspected, as timely intervention can protect vision.

This quiz provides an overview of blepharitis, focusing on its classification into anterior, posterior, and mixed lid margin disease. Participants will learn about the associated symptoms and signs of each type, as well as predisposing conditions. Test your knowledge about this common ocular condition and its implications.