Blepharitis - UpToDate

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Blepharitis
Author: Roni M Shtein, MD
Section Editor: Deborah S Jacobs, MD
Deputy Editor: Jane Givens, MD, MSCE
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2022. | This topic last updated: Aug 11, 2022.
INTRODUCTION
Blepharitis is a common chronic ophthalmologic condition characterized by inflammation of

the eyelid margin associated with eye irritation. Other related eyelid conditions are
discussed separately, as is dry eye disease, which is a frequent complication of blepharitis.
(See "Eyelid lesions" and "Dry eye disease".)
CLASSIFICATION AND PATHOPHYSIOLOGY
Blepharitis is classified as either posterior or anterior. However, there tends to be

considerable overlap of both types, with a predominance of posterior. The etiology and
pathophysiology of blepharitis differ somewhat based on the type (posterior versus
anterior).
Posterior blepharitis — Posterior blepharitis, the more common type, is characterized by

inflammation of the inner portion of the eyelid at the level of the meibomian glands
( picture 1) [1]. Meibomian glands are modified sebaceous glands, located within the tarsal
plates of the eyelids, responsible for secretion of the oily layer of the tear film ( figure 1).
This oily layer prevents tear evaporation, reduces the surface tension of the tear layer, and
facilitates the spread of tears [2]. It is critical for normal eye lubrication.
Hyperkeratinization of the meibomian gland ductal epithelium is an early finding in patients

with posterior blepharitis [3]. Altered lipid composition in gland secretions leads to instability
of the tear film [4-10]. The abnormal secretions also have a direct toxic effect on the ocular
surface [7,11]. Additionally, the altered lipid composition provides an environment that
promotes bacterial growth, which perpetuates the meibomian gland abnormalities. Long-
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term inflammation leads to gland dysfunction and fibrosis as well as damage to the eyelid
and ocular surface.
Anterior blepharitis — Anterior blepharitis is characterized by inflammation at the base of

the eyelashes ( picture 2). Patients with anterior blepharitis tend to be younger than those
with posterior blepharitis [4]. The pathophysiology of anterior blepharitis is not completely
understood, although lid-colonizing staphylococcal bacteria appear to play a role in some
cases [12]. Anterior blepharitis can be further categorized as staphylococcal or seborrheic
type:
● Staphylococcal type is characterized by fibrinous scales and crust around the eyelashes
caused by colonization of the eyelids by Staphylococcus aureus and coagulase-negative
staphylococci [13-16]. Staphylococci may alter meibomian gland secretion and cause
blepharitis via various mechanisms, including direct infection of the lids, production of
staphylococcal exotoxin, and provoking an allergic response [11,13-16]. It is likely that a
combination of these factors is responsible for the manifestations of anterior
blepharitis.
● Seborrheic type is characterized by dandruff-like skin changes and greasy scales

around the base of the eyelids [11].
PREDISPOSING CONDITIONS
Several conditions can predispose patients to blepharitis, although it may occur in their
absence. These conditions fall into the following categories: inflammatory skin conditions,
infections, irritants or allergens, and medications ( table 1). Several of these conditions are
associated with both posterior and anterior blepharitis:
● Chronic inflammatory skin conditions such as rosacea and seborrheic dermatitis may
cause posterior blepharitis [2,17,18]. Other possible causes of both anterior and
posterior blepharitis include contact (allergic) dermatitis, eczema, and psoriasis [19].
Blepharitis in patients with such underlying chronic dermatoses tends to be more
severe, with increased redness, eyelid swelling, and discomfort. (See "Seborrheic
dermatitis in adolescents and adults".)
● Colonization of the eyelids by S. aureus and coagulase-negative staphylococci can cause

anterior blepharitis as described above. Chronic colonization may also play a role in
posterior blepharitis, although it is less well studied than in anterior blepharitis. The
bacteria that comprise the lid and conjunctival flora in posterior blepharitis are the
same as those on normal skin but present in greater numbers [14]. They include
coagulase-negative staphylococci, Corynebacterium species, and Cutibacterium acnes

[4,5,15]. Bacterial lipase produced by colonizing bacteria on the ocular surface may
contribute to the differences in lipid composition in the tear film in patients with
blepharitis [2,13,16,20].
Demodex folliculorum is a parasite that has been identified in 30 percent of patients with
chronic anterior blepharitis but is also found with approximately the same prevalence
in asymptomatic persons [21,22]. However, it is clearly a contributing factor in some
patients as evidenced by the improvement seen in response to eradicative therapy [22].
A second species, Demodex brevis, has been associated with posterior blepharitis.
● Contact blepharitis is an acute inflammatory reaction of the skin of the eyelids, usually
occurring as a reaction to an irritant (eg, cosmetics) [19]. Factors that may provoke or
exacerbate blepharitis symptoms include allergic conjunctivitis, cigarette smoking, and
contact lens use [23].
● Retinoids (eg, isotretinoin) and chemotherapeutic agents (eg, 5-fluorouracil) may

predispose to posterior blepharitis [23].
CLINICAL FINDINGS
Symptoms — Patients with either anterior or posterior blepharitis generally present with

chronic recurrent symptoms, which may vary over time, involving both eyes. These include:
● Red, swollen, or itchy eyelids

● Gritty or burning sensation
● “Pink eyes” (see "The red eye: Evaluation and management")
● Excessive tearing (which can paradoxically be a sign of dry eye)
● Crusting or matting of eyelashes in the morning
● Flaking or scaling of the eyelid skin
Advanced cases may also have:
● Light sensitivity
● Blurred vision (transient in nature; usually improves with blinking)
Dry eye disease ( picture 3) is a frequent complication of blepharitis, occurring in 25 to 40

percent of patients [24]. (See "Dry eye disease".)
Blepharitis is more common in adults than children, and its prevalence increases with age.
However, children can have dramatic episodes of anterior and/or posterior blepharitis, often
characterized by more conjunctival and corneal findings than in adults [25,26].

Blepharitis related to Demodex infestation characteristically presents with cylindrical

dandruff or “sleeves” on the eyelashes [27].
Contact (allergic) blepharitis from an irritant (eg, cosmetics) manifests with red, swollen, and
itchy eyelids occurring acutely after exposure.
Symptoms of an associated chronic inflammatory skin condition may also be noted (eg,
facial redness or flushing suggestive of rosacea; itchy and flaking skin involving the scalp,
external ear, central face, or trunk suggestive of seborrheic dermatitis). (See "Rosacea:
Pathogenesis, clinical features, and diagnosis", section on 'Clinical features' and "Seborrheic
dermatitis in adolescents and adults", section on 'Clinical manifestations'.)
Eye examination — The major findings of blepharitis on physical examination include pink

or irritated eyelids, which may be associated with crusting.
The eyes should be examined using a slit lamp or, if a slit lamp is not available, a focused
light source such as a penlight or otoscope lamp. The eyelids, conjunctivae, tear film, and
cornea can be examined more closely with a slit lamp; however, it is generally not necessary
to establish the diagnosis.
Eyelids and eyelashes
● The eyelid edges in patients with blepharitis often appear pink or irritated ( picture 1
and picture 2). Crusting of the lashes or lid margins may also be visible.
● Patients with anterior blepharitis typically have adherent material around their
eyelashes. In the seborrheic variant of anterior blepharitis, there are often greasy-
appearing flakes; whereas in the staphylococcal variant, a hard cylindrical crust
develops around the eyelash (called a "collarette") [28].
● In posterior blepharitis, it is common to see enlargement of the meibomian gland

openings and plugging with thickened, waxy secretions appearing as white or yellow
mounds at the gland opening ( picture 4).
● The presence of cylindrical dandruff or “sleeves” on the eyelashes can indicate Demodex
infection. (See 'Ancillary testing' below.)
● Chronic inflammation can be detected on examination:
The eyelashes should be carefully evaluated as chronic inflammation can lead to

trichiasis (misdirected eyelashes), madarosis (loss of lashes), poliosis (loss of
pigmentation of lashes), or distichiasis (abnormal growth of eyelashes from meibomian
gland orifices). Chronic inflammation can lead to structural changes resulting in

entropion (inward turning of eyelid) ( picture 5) or ectropion (outward turning of

eyelid) ( picture 6).
Other findings that are suggestive of chronic inflammation include neovascularization

and dilation of blood vessels of the lid margins, thickening of the lid skin, irregularity of
the lid contour, and ulcerations along the lid margin. These findings can be observed
with a penlight but are more easily appreciated with slit-lamp magnification.
Conjunctivae — Diffuse conjunctival injection is a common but nonspecific finding in

patients with blepharitis. Injection may be more prominent on the palpebral conjunctiva [2].
Blepharitis can also be associated with a papillary conjunctival reaction ( picture 7), which
appears as raised but flat-topped nodules with central vessels.
Tear film — Tear film irregularities are suggested by the presence of debris and/or a foamy
appearance on slit-lamp examination. Tear film stability can be formally assessed by
measuring the tear break-up time or tear evaporation rate.
Tear break-up time is performed by examining the tear film with a slit lamp using blue light
after instilling fluorescein stain in the eye. A healthy tear film appears as a green sheen that
remains stable for at least 10 seconds. An abnormal tear film becomes irregular or breaks up
in less than 10 seconds.
The tear evaporation rate, which is more often used in research than clinical practice, also
assesses the tear film stability and is measured with advanced imaging instruments that use
interferometry.
Cornea — Corneal abnormalities are infrequent complications of blepharitis. They are best

seen with a slit lamp and may include the following:
● Erosions – Corneal erosions are most commonly found where the inflamed lid margins
cross the cornea at the 2, 4, 8, and 10 o'clock positions. Punctate epithelial erosions
may appear in the inferior third of the cornea [11]. Similar erosions may be associated
with dry eyes, but in that condition they are more commonly distributed throughout
the interpalpebral space. (See "Dry eye disease".)
● Infiltrates – Marginal corneal infiltrates may occur as a hypersensitivity reaction to

staphylococcal antigens [29]. These appear as an area of superficial whitening near the
limbus (border of the cornea and sclera). An area of clear cornea between the limbus
and the infiltrate is characteristic.
● Nodules – Corneal nodules (phlyctenules) develop near the limbus and then spread
onto the cornea, carrying behind them a leash of vessels. They are considered to be
another form of hypersensitivity reaction to staphylococcal antigens [30].

● Ulcers – Rarely, corneal marginal ulcers can develop in the setting of blepharitis. These
must be recognized and treated appropriately to avoid progression to corneal
perforation.
● Scarring – Chronic irritation and recurrent corneal infiltrates can lead to scarring and
development of a superficial corneal pannus (“pseudo-pterygium”) ( picture 8).
Ancillary testing — Ancillary testing (eg, bacterial culture, microscopic examination of the

eyelash, imaging techniques [meibography]) is not necessary to establish the diagnosis of
blepharitis but may have a role in some clinical settings. Culture of the eyelid margins has
limited utility because of the difficulty in distinguishing bacterial infection from colonization.
However, it may be useful in patients with severe blepharitis and in those who are not
responding to empiric therapy [23].
Epilation of the eyelashes for microscopic examination to detect Demodex mites is warranted
when the clinical presentation (eg, presence of cylindrical dandruff or “sleeves” on the
eyelashes) is suggestive of this diagnosis or when there is severe or refractory blepharitis
[23]. It is performed by the ophthalmologist placing the eyelashes on a glass slide and
examining under a cover slip after a drop of fluorescein has been added.
Techniques of imaging and measuring the meibomian gland size and function, ocular
surface, and tear film dynamics are available and can provide more objective measures of
the eyelids and tear function in patients with blepharitis [31-33]. However, these are not
routinely used in clinical practice.
DIAGNOSIS
Blepharitis is a clinical diagnosis based on characteristic findings of redness and irritation of

the eyelid margin associated with crusting or flakes on the lashes or lid margins ( picture 1
and picture 2). It is a bilateral condition but can have asymmetric findings. Slit lamp allows
for more detailed examination of the meibomian glands, which can help distinguish
between posterior and anterior blepharitis. However, it is generally not necessary to make
the diagnosis. (See 'Eye examination' above.)
The diagnosis of blepharitis can be made by the primary care practitioner in most instances.
If the diagnosis is unclear based upon clinical findings, referral to an ophthalmologist for slit-
lamp examination (if not available in primary care site) is advised. (See 'Indications for
referral' below.)
DIFFERENTIAL DIAGNOSIS

Blepharitis can be distinguished from other conditions associated with redness and
discomfort of the eyelid based upon the history and physical examination:
● Conjunctivitis – Conjunctivitis, which may be infectious, allergic, or toxic in etiology, is

characterized by erythema of eye (rather than eyelids) and the presence of clear or
purulent discharge. Vision should be normal, and there should be no evidence of other
causes of “red eye” (eg, keratitis, iritis). (See "Conjunctivitis", section on 'Evaluation and
diagnosis'.)
● Hordeolum – A hordeolum (stye) is an acute inflammation of an oil gland of the eyelid

that presents as a red tender bump on the eyelid ( picture 9). It can be associated
with blepharitis because abnormal oily secretions block lid glands that may become
secondarily infected. Treatment involves application of warm, moist compresses four
times a day.
● Chalazion – A chalazion is a firm, non-tender bump on the eyelid that represents a

chronic sterile inflammation of an oil gland of the eyelid ( picture 10). It results from
a granulomatous inflammatory reaction to the lipid content of the blocked lid gland
( figure 2) [2]. Treatment involves application of warm, moist compresses four times
a day. If the symptoms do not respond after several weeks, incision and curettage or
intralesional glucocorticoid injection can be performed.
● Eyelid malignancy – A malignant tumor of the lid skin (sebaceous carcinoma) should
be suspected in a patient with persistent unilateral eyelid inflammation ( picture 11)
[34-37]. Other symptoms of malignancy include a nodular mass, ulceration, extensive
scarring, or conjunctival nodules with inflammation [23]. Eyelid malignancy should be
considered in patients with unilateral blepharitis that does not respond to treatment.
The diagnosis it is confirmed with biopsy. (See "Eyelid lesions", section on 'Sebaceous
carcinoma'.)
INDICATIONS FOR REFERRAL
Most patients with blepharitis can be diagnosed and managed by the primary care
practitioner. However, referral to an ophthalmologist is warranted if any of the following are
present [23]:
● Severe eye redness, pain, or light sensitivity.
● Impaired vision.
● Corneal abnormalities (eg, erosions, ulcers, scarring).

● Uncertain diagnosis or concern for malignancy. (See 'Differential diagnosis' above.)
● Suspicion of Demodex infection. (See 'Ancillary testing' above.)
● Severe or refractory symptoms with poor response to standard management. We

define severe symptoms as those affecting vision or quality of life. (See 'Severe or
continuing symptoms' below.)
MANAGEMENT
General approach — Patients should be counseled that blepharitis is a chronic condition

and many people will require long-term care. Good lid hygiene is the mainstay of treatment
for all forms of blepharitis. The goal is to alleviate symptoms and to develop a maintenance
regimen to prevent or minimize future exacerbations. Our management approach is based
on clinical experience, limited clinical trial and observational data, and consensus expert
opinion [38,39]. Our approach is presented in the algorithm ( algorithm 1).
All patients should be advised to eliminate or limit potential triggers or exacerbating factors
(eg, allergens, cigarette smoking). Contact lenses may continue to be worn if comfortable.
Some wearers may benefit from refitting of lenses or the use of a different lens material.
The management of contact (allergic) blepharitis consists of eliminating use of the offending
agent (eg, cosmetics). Patients who use cosmetics should be vigilant about removing their
makeup at night, cleaning applicators, and avoiding old or expired products.
Mild to moderate symptoms — For patients with mild to moderate symptoms,

management consists of warm compresses, lid massage, lid washing, and artificial tears.
These patients can generally be managed by the primary care practitioner.
Blepharitis is a chronic condition that requires long-term management. The intensity level of
treatment varies based on patient symptoms. Most patients with mild to moderate
symptoms respond well to the basic interventions described below. Although it may vary
based on the severity of symptoms, in general, these measures should be trialed for
approximately six weeks before moving on to other treatments. The efficacy of lid hygiene
measures for symptom relief in patients with chronic posterior or anterior blepharitis has
been demonstrated in several small clinical trials [38].
Warm compresses — Application of heat to the lids and meibomian glands can liquefy the
abnormal solidified secretions by heating them above their melting point. Heat may also
promote increased circulation in the meibomian glands and thereby increase the quantity of
secretions.

Patients should be advised to soak a wash cloth in warm (not hot) water and place it over the
eyes. As the wash cloth cools, it should be rewarmed and replaced for a total of 5 to 10
minutes of soaking time. Warm compresses should be applied two to four times a day as
long as the patient has symptoms and at a decreased frequency in the maintenance phase.
Numerous eyelid-warming devices are commercially available [40,41]. Such devices are
unlikely to be more or less efficacious than using a warm wash cloth, but some patients may
prefer them.
Lid massage — Lid massage may help empty the meibomian glands and improve
secretion, especially in patients with posterior blepharitis and meibomian gland inspissation.
Lid massage should be performed immediately following application of a warm compress, a
few times a day. Either the wash cloth that was used for the compress or a clean fingertip
should be used to gently massage the edge of the eyelid towards the eye with a gentle
circular motion.
Lid washing — Patients with accumulation of debris on the eyelashes may benefit from
gentle washing of the eyelid margins following the use of a warm compress. Either warm
water or very dilute baby shampoo can be placed on a clean wash cloth, gauze pad, or
cotton swab. The patient should then be advised to gently clean along the lashes and lid
margin to remove the accumulated material with care to avoid contacting the ocular surface.
If shampoo is used, thorough rinsing is recommended. Vigorous washing should be avoided,
as it may cause more irritation. Commercially available eyelid scrub solutions are safe and
effective and may be preferred for convenience and ease of use [42,43].
Artificial tears — Patients often need to use supplemental artificial tear eye drops to treat
the dryness associated with blepharitis (see "Dry eye disease"). Ocular lubrication may also
improve contact lens tolerance in patients with blepharitis.
Ineffective therapies — We do not routinely suggest omega-3 fatty acid supplementation

for patients with blepharitis. Clinical trials of oral omega-3 fatty acid supplementation for
treatment of meibomian gland dysfunction, posterior blepharitis, and dry eye have shown
mixed results [44-50]. Most studies have been small and have evaluated surrogate outcomes
such as tear break-up time. In the largest trial, there was no apparent benefit [47].
Severe or continuing symptoms
Overview — For patients who do not respond to the symptomatic measures described

above and for those with severe symptoms (affecting vision or quality of life), we suggest
initiating treatment with topical or oral antibiotic therapy in addition to continuing
symptomatic measures. Because of the potential for systemic side effects with oral drugs,
topical therapy is usually tried first. Patients with severe or refractory symptoms should be
referred to an ophthalmologist for confirmation of the diagnosis and for monitoring during

treatment. Other treatment options include topical glucocorticoids and cyclosporine (only to
be prescribed by or in consultation with an ophthalmologist).
Topical antibiotics — We suggest topical antibiotic therapy for patients who do not
respond to the symptomatic measures described above.
Topical ophthalmic antibiotic ointments (eg, bacitracin, erythromycin) may improve

symptoms by reducing the bacterial load of the lashes and conjunctivae. These agents tend
to be more effective in anterior blepharitis when the inflammation is more localized to the
lash follicles than the meibomian glands; however, as previously described, there is
considerable overlap between anterior and posterior blepharitis, and patients with posterior
blepharitis may also respond. Both bacitracin and erythromycin have broad spectrum
antimicrobial activity and are generally well tolerated. Antibiotic ointment is placed directly
onto the lid margin once daily at bedtime for two weeks. Once symptoms improve,
treatment can be stopped, but lid hygiene measures should be continued. (See 'Lid washing'
above.)
Topical azithromycin ophthalmic solution 1% is an alternative agent particularly for patients

with posterior blepharitis. Dosing is one drop twice daily for 10 to 14 days. Azithromycin has
been shown to improve meibomian gland secretions and to decrease eyelid redness
compared with warm compresses alone [51].
A systematic review of randomized controlled trials and quasi-randomized controlled trials of

patients with chronic posterior or anterior blepharitis found that topical antibiotics were
effective in providing symptomatic relief and in eradicating bacteria at the lid margin in
patients with anterior blepharitis [38]. Additional studies have suggested that antibiotics
may have a direct effect on improving meibomian gland function [52,53].
Oral antibiotics after trial of topical antibiotics — Oral antibiotics (eg, doxycycline,

tetracycline, azithromycin), are generally reserved for patients with chronic moderate to
severe blepharitis that have an inadequate response to topical antibiotic therapy. Treatment
is initiated with doxycycline 100 mg or tetracycline 1000 mg daily in divided doses and
tapered after improvement (usually two to four weeks) to doxycycline 50 mg or tetracycline
250 to 500 mg once a day. An alternative regimen is azithromycin 500 mg on day 1, followed
by 250 mg for four more days.
Evidence supporting the use of oral antibiotics to treat blepharitis is based on mainly
observational studies. In a systematic review of eight studies (one randomized trial and
seven observational studies) evaluating antibiotic therapy for treatment of posterior
blepharitis, all of the included studies documented improvements in ocular surface disease
[54]. Most of the studies were small (five included ≤20 patients), and each used a different

treatment regimen, including doxycycline, minocycline, or azithromycin. Another systematic

review found that the evidence for efficacy of oral antibiotics was inconclusive [38].
Tetracyclines effectively reduce the load of colonizing lid and conjunctival bacteria [55]. They
also decrease keratinization and bacterial lipase production [56-58]. Tetracyclines may be
especially useful in patients with ocular manifestations of rosacea [59]. In addition, they are
associated with reduction of matrix metalloproteinase activity that may play a role in chronic
blepharitis [60].
Tetracyclines may cause photosensitization, gastrointestinal side effects, and pseudotumor

cerebri, as well as interfere with warfarin and the effectiveness of oral contraceptives. They
are contraindicated in pregnant or nursing women and in children under 12 years of age.
Azithromycin or other macrolides should be used in these settings. Nausea and other
gastrointestinal side effects are common with azithromycin.
Refractory symptoms — Patients with refractory symptoms should be referred to an

ophthalmologist.
Topical glucocorticoids — Topical glucocorticoid eyedrops, gels, and ointments are

generally reserved for patients with blepharitis that is unresponsive to other therapies [23].
Low-potency agents such as rimexolone, loteprednol etabonate, and fluorometholone are
preferred to reduce the risk for adverse effects. Topical glucocorticoids should only be
prescribed by or in consultation with an ophthalmologist. Treatment should be limited to
two to three weeks to reduce the risk for cataract formation or glaucoma. If topical
glucocorticoids are prescribed, patients should be reevaluated in a few weeks to measure
intraocular pressure and to determine response to treatment.
Small clinical trials demonstrated short-term improvements in symptom scores, clinical

findings (eg, lid margin injection, tear break-up time, meibomian gland expressibility), and
tear cytokine levels in patients treated with topical glucocorticoids compared with controls
[61,62]. A systematic review concluded that the evidence for the effectiveness of topical
glucocorticoids in blepharitis is inconclusive [38].
Topical cyclosporine — Topical cyclosporine should be reserved for patients with

blepharitis who do not respond to standard therapies and should be prescribed by an
ophthalmologist [23]. It is available as 0.05% eye drops.
Several small prospective studies have demonstrated improvements in objective measures

of meibomian gland dysfunction (eg, lid margin injection, tear break-up time, meibomian
gland expressibility) in patients treated with topical cyclosporine compared with controls;
only one study demonstrated improvement in symptoms [63-65].

The choice between topical glucocorticoids and topical cyclosporine is based on clinician and
patient preference. In our experience, topical glucocorticoids tend to be more effective than
topical cyclosporine but have greater potential for adverse effects.
Topical cyclosporine is approved by the US Food and Drug Administration (FDA) and
European Medicines Agency (EMA) for treatment of dry eyes, but its use in treatment of
blepharitis in the absence of dry eye disease is “off-label.” The use of topical cyclosporine in
management of dry eyes is discussed separately. (See "Dry eye disease", section on 'Topical
cyclosporine'.)
“Off-label” use of topical tacrolimus has also been described. Limited evidence suggests that
tacrolimus can improve symptoms and ocular surface status in patients with refractory
posterior blepharitis [66].
Demodex infestation — Blepharitis associated with Demodex species infestation can be

treated either with oral ivermectin (200 mcg/kg in a single dose and repeated once in one
week), topical tea tree oil eyelid scrubs (administered weekly for six weeks) or tea tree
shampoo (applied daily for six weeks) [23,67,68]. Demodex infestation is suggested by the
presence of cylindrical dandruff or “sleeves” on the eyelashes or by severe or refractory
blepharitis. The diagnosis is confirmed by the presence of Demodex mites on microscopic
examination. (See 'Ancillary testing' above.)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
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grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Blepharitis (The Basics)" and "Patient education:
Stye (hordeolum) (The Basics)" and "Patient education: Chalazion (The Basics)")
SUMMARY AND RECOMMENDATIONS

● Classification and pathophysiology – Blepharitis is a common chronic

ophthalmologic condition characterized by inflammation of the eyelids associated with
eye irritation. The etiology and pathophysiology of blepharitis differ somewhat based
on the type (posterior versus anterior) ( table 1). However, there is considerable
overlap between these categories.
• Posterior blepharitis – Posterior blepharitis, the more common condition, is

characterized by inflammation of the inner portion of the eyelid at the level of the
meibomian glands (modified sebaceous glands located within the tarsal plates of
the eyelids), which are dysfunctional ( picture 1). It can be associated with rosacea
or seborrheic dermatitis.
• Anterior blepharitis – Anterior blepharitis is characterized by inflammation at the

base of the eyelashes ( picture 2). It can be associated with staphylococcal
colonization or seborrhea. (See 'Classification and pathophysiology' above.)
● Predisposing conditions – Several conditions can predispose patients to blepharitis,

although it may occur in their absence. These conditions fall into the following
categories: inflammatory skin conditions, infections, irritants or allergens, and
medications ( table 1). Several of these conditions are associated with both posterior
and anterior blepharitis. (See 'Predisposing conditions' above.)
● Clinical features – Patients with blepharitis generally present with symptoms of

chronic irritation involving both eyes. These include red, swollen, or itchy eyelids; gritty
or burning sensation; “pink eyes”; excessive tearing (which can paradoxically be a sign
of dry eye); crusting or matting of eyelashes in the morning; flaking or scaling of the
eyelid skin; light sensitivity; and blurred vision (transient in nature, usually improves
with blinking). The eyelid edges often appear pink or irritated. Crusting of the lashes or
lid margins may also be visible. (See 'Clinical findings' above.)
● Diagnosis – Blepharitis is a clinical diagnosis based on characteristic findings of

redness and irritation of the eyelid margin associated with crusting or flakes on the
lashes or lid margins ( picture 1 and picture 2). Slit lamp allows for more detailed
examination of the meibomian glands, which can help distinguish between posterior
and anterior blepharitis. However, it is generally not necessary to make the distinction.
(See 'Diagnosis' above.)
● Differential diagnosis – The differential diagnosis for blepharitis includes other

conditions associated with redness and discomfort of the eyelid such as conjunctivitis,
hordeolum (stye), chalazion, and eyelid malignancy. Blepharitis is distinguished from
these conditions based upon the history and physical examination. (See 'Differential
diagnosis' above.)

● Indications for ophthalmologic referral – Indications for referral to an

ophthalmologist include severe eye redness or pain, light sensitivity, impaired vision,
corneal abnormalities (eg, erosions, ulcers, scarring), uncertain diagnosis or concern
for malignancy, Demodex infection, or severe or refractory symptoms. (See 'Indications
for referral' above.)
● General treatment measures – Good lid hygiene is the mainstay of treatment for all
forms of blepharitis. In addition, patients should be advised to eliminate or limit
potential triggers or exacerbating factors (eg, allergens, cigarette smoking, contact
lenses). The goal is to alleviate symptoms and to develop a maintenance regimen to
prevent or minimize future exacerbations. Blepharitis is a chronic condition that
requires long-term management. The intensity level of treatment varies based on
patient symptoms (see 'Management' above). Our approach is presented in the
algorithm ( algorithm 1):
• Treatment for mild or moderate symptoms – All patients with blepharitis should
be advised to use warm compresses, lid massage, and lid washing. This treatment is
typically sufficient in patients with mild to moderate symptoms. In addition, patients
may benefit from supplemental artificial tear eye drops to treat the dryness
associated with blepharitis. Patients whose symptoms do not respond to these
measures should be treated with topical antibiotics. (See 'Mild to moderate
symptoms' above.)
• Treatment for more severe symptoms or continuing symptoms – Patients who

present with more severe symptoms or who do not respond to the symptomatic
measures described above should generally be managed by an ophthalmologist. In
such patients, we suggest addition of topical antibiotic therapy to symptomatic
measures (Grade 2C). Although oral antibiotic therapy is an alternative, topical
therapy is usually tried first because of the potential for systemic side effects with
oral drugs.
For most patients, antibiotic ointment (eg, bacitracin, erythromycin) is placed

directly onto the lid margin once daily at bedtime. Topical azithromycin ophthalmic
solution 1% is an alternative agent for patients with predominantly posterior
blepharitis. Dosing is one drop twice daily for 10 to 14 days. Once symptoms
improve (generally one to two weeks), treatment can be stopped, but lid hygiene
measures should be continued.
In patients whose response to topical therapy is inadequate, we suggest switching

to oral antibiotic therapy rather than using glucocorticoids or cyclosporine (Grade
2C). Doxycycline, tetracycline, or azithromycin are typically used. (See 'Topical
antibiotics' above and 'Oral antibiotics after trial of topical antibiotics' above.)
• Treatment of refractory symptoms – Patients with symptoms refractory to

antibiotic therapy can be treated with topical glucocorticoids and cyclosporine.
These agents should only be prescribed by or in consultation with an
ophthalmologist. (See 'Severe or continuing symptoms' above.)
Use of UpToDate is subject to the Terms of Use.
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Topic 6915 Version 47.0

GRAPHICS
Posterior blepharitis
Lower eyelid with characteristic posterior lid inflammation and oily

white plugs visible at the meibomian gland openings.
Graphic 61924 Version 1.0

The anatomy of the eyelid

Anterior blepharitis
Lower lid with inflammation with characteristic scales on the

eyelashes.

Causes of and contributing factors to blepharitis
Comments
Inflammatory skin conditions
Rosacea More commonly causes posterior blepharitis

May be associated with facial redness or flushing
Seborrheic dermatitis More commonly causes anterior blepharitis

Characterized by flaking and greasy scales at base of eyelids
May be associated with scalp dandruff and other manifestations
Atopic dermatitis Characterized by edema, hyperemia, and scaling of lash line of

(eczema) lid margins
May be associated with other manifestations (eg, chronic
pruritic erythematous rash involving skin creases)
Psoriasis Characterized by flaking or crusting of the eyelashes and

swollen eyelids
May be associated with other manifestations (eg, well-defined
erythematous plaques with scale involving elbows and knees)
Infections
Bacterial "over- Most commonly causes anterior blepharitis

colonization" Characterized by fibrinous scales and crust around the
eyelashes
Staphylococcus aureus and coagulase-negative staphylococci are
the most common organisms
Other lid-colonizing bacteria (eg, Corynebacterium species,
Cutibacterium acnes) may play a role
Parasitic infestation Inhabit eyelid follicles (Demodex folliculorum) and meibomian

(Demodex species) glands (Demodex brevis)
Characterized by follicular pustules or papules
Scales may form "collarettes" (cylindrical dandruff around the
lash base)
Not all patients with Demodex infestation develop blepharitis
Irritants and allergens (contact blepharitis)
Cosmetics, cigarette Characterized by erythematous, swollen, and itchy eyelids

smoke, contact Reaction to local irritant
lenses/contact lens Improves with removal/avoidance of offending agent
solution
Medications
Retinoids (eg, Typically causes posterior blepharitis (meibomian gland

isotretinoin), dysfunction)
chemotherapeutic Commonly associated with dry eye

agents (eg, 5- Generally resolves after discontinuing medication
fluorouracil)

Dry eye disease with conjunctival injection,

associated neovascularization of the cornea, and a
central corneal opacity/scarring

Plugged glands
High magnification view of meibomian gland openings of the eyelid

with mounds of thickened, waxy secretions plugging the gland
openings.

Entropion
Inward turning of the lower eyelid with eyelashes rubbing against

the ocular surface.

Ectropion
Outward turning of the lower eyelid with increased exposure of the

ocular surface and sensitive mucous membrane of the inner lid, as
well as disruption of normal tear drainage patterns.

Giant papillary conjunctivitis on the upper tarsal

conjunctiva
Giant papillary conjunctivitis (GPC) formation on the upper tarsal

conjunctiva of a patient from contact lens overwear. GPC can also be
due to other prostheses or foreign objects, such as sutures, that
abrade the surface of the conjunctiva.

Corneal pannus
An area of corneal pannus with superficial blood vessel growth onto

the inferior cornea at the 5 o'clock position.

Hordeolum / Stye
Acute plugging of a meibomian gland and associate inflammation

results in a tender, red bump seen in the medial lower lid.

Chalazion
Chronic meibomian gland plugging leads to granulomatous

inflammation seen as a yellow-white bump on the inner aspect of
the mid-lower lid.

Distinguishing hordeolum (stye) from chalazion


Sebaceous carcinoma of the eyelid
Mimic of blepharitis, but with only unilateral findings. Here the

bump on the medial upper lid is concerning due to its vascularity
and alteration of both the lid margin architecture and the lash line.

Treatment of non-contact sensitivity blepharitis
This algorithm excludes blepharitis due to contact sensitivity.

Contributor Disclosures
Roni M Shtein, MD No relevant financial relationship(s) with ineligible companies to
disclose. Deborah S Jacobs, MD Consultant/Advisory Boards:
Cloudbreak[Ophthalmology/pterygium];Dompé[Ophthalmology/neurotrophic keratitis].
All of the
relevant financial relationships listed have been mitigated. Jane Givens, MD, MSCE No relevant
financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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18/10/2022, 15:43 Blepharitis - UpToDate

Official reprint from UpToDate®

Blepharitis is a common chronic ophthalmologic condition characterized by inflammation of

CLASSIFICATION AND PATHOPHYSIOLOGY

Blepharitis is classified as either posterior or anterior. However, there tends to be

Posterior blepharitis — Posterior blepharitis, the more common type, is characterized by

Hyperkeratinization of the meibomian gland ductal epithelium is an early finding in patients

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Anterior blepharitis — Anterior blepharitis is characterized by inflammation at the base of

● Seborrheic type is characterized by dandruff-like skin changes and greasy scales

● Colonization of the eyelids by S. aureus and coagulase-negative staphylococci can cause

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● Retinoids (eg, isotretinoin) and chemotherapeutic agents (eg, 5-fluorouracil) may

Symptoms — Patients with either anterior or posterior blepharitis generally present with

● Red, swollen, or itchy eyelids

Advanced cases may also have:

Dry eye disease ( picture 3) is a frequent complication of blepharitis, occurring in 25 to 40

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Blepharitis related to Demodex infestation characteristically presents with cylindrical

Eye examination — The major findings of blepharitis on physical examination include pink

Eyelids and eyelashes

● In posterior blepharitis, it is common to see enlargement of the meibomian gland

● Chronic inflammation can be detected on examination:

The eyelashes should be carefully evaluated as chronic inflammation can lead to

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entropion (inward turning of eyelid) ( picture 5) or ectropion (outward turning of

Other findings that are suggestive of chronic inflammation include neovascularization

Conjunctivae — Diffuse conjunctival injection is a common but nonspecific finding in

Cornea — Corneal abnormalities are infrequent complications of blepharitis. They are best

● Infiltrates – Marginal corneal infiltrates may occur as a hypersensitivity reaction to

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Ancillary testing — Ancillary testing (eg, bacterial culture, microscopic examination of the

Blepharitis is a clinical diagnosis based on characteristic findings of redness and irritation of

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● Conjunctivitis – Conjunctivitis, which may be infectious, allergic, or toxic in etiology, is

● Hordeolum – A hordeolum (stye) is an acute inflammation of an oil gland of the eyelid

● Chalazion – A chalazion is a firm, non-tender bump on the eyelid that represents a

INDICATIONS FOR REFERRAL

● Severe eye redness, pain, or light sensitivity.

● Corneal abnormalities (eg, erosions, ulcers, scarring).

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● Uncertain diagnosis or concern for malignancy. (See 'Differential diagnosis' above.)

● Suspicion of Demodex infection. (See 'Ancillary testing' above.)

● Severe or refractory symptoms with poor response to standard management. We

General approach — Patients should be counseled that blepharitis is a chronic condition

Mild to moderate symptoms — For patients with mild to moderate symptoms,

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Ineffective therapies — We do not routinely suggest omega-3 fatty acid supplementation

Severe or continuing symptoms

Overview — For patients who do not respond to the symptomatic measures described

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Topical ophthalmic antibiotic ointments (eg, bacitracin, erythromycin) may improve

Topical azithromycin ophthalmic solution 1% is an alternative agent particularly for patients

A systematic review of randomized controlled trials and quasi-randomized controlled trials of

Oral antibiotics after trial of topical antibiotics — Oral antibiotics (eg, doxycycline,

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treatment regimen, including doxycycline, minocycline, or azithromycin. Another systematic

Tetracyclines may cause photosensitization, gastrointestinal side effects, and pseudotumor

Refractory symptoms — Patients with refractory symptoms should be referred to an

Topical glucocorticoids — Topical glucocorticoid eyedrops, gels, and ointments are