Clinical Diagnosis and Management of Blepharitis

Key Diagnostic Elements

The American Academy of Ophthalmology recommends that symptoms including redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, blurring or fluctuating vision, contact lens intolerance, photophobia, increased frequency of blinking, and recurrent hordeolum be considered in the diagnosis of blepharitis 1
Time of day when symptoms occur, such as morning symptoms typical of blepharitis, and evening symptoms more typical of aqueous deficient dry eye, should be evaluated in the diagnosis of blepharitis 3
The presence of exacerbating factors such as smoke, allergens, wind, contact lenses, low humidity, retinoids, diet, alcohol consumption, and eye makeup should be considered in the diagnosis of blepharitis 3
Associated systemic conditions including rosacea, atopy, psoriasis, and graft-versus-host disease should be evaluated in the diagnosis of blepharitis 3
Medication history, particularly isotretinoin and dupilumab which are associated with blepharitis, should be considered in the diagnosis of blepharitis 3, 4

Microbiologic cultures of eyelid margins for patients with recurrent anterior blepharitis with severe inflammation or those not responding to therapy may be necessary 6
Microscopic evaluation of epilated eyelashes for Demodex mites may be performed to aid in the diagnosis of blepharitis 6
Assessment of meibomian gland expression by applying pressure to lower eyelids with fingers or cotton-tipped applicator may be used to evaluate meibomian gland dysfunction 6

Consider carcinoma in cases of chronic blepharitis unresponsive to therapy, especially with unilateral involvement 6
Eyelid biopsy may be indicated for marked asymmetry, resistance to therapy, or unifocal recurrent chalazia 6

Warm compresses and eyelid hygiene/cleansing form the mainstay of treatment for blepharitis 7
Eyelid massage for meibomian gland dysfunction to express the glands may be beneficial in the treatment of blepharitis 7
Topical antibiotics to reduce bacterial load may be used in the treatment of blepharitis 7
Topical corticosteroids for marked inflammation may be used in the treatment of blepharitis 7

Blepharitis is a chronic condition with periods of exacerbation and remission; patients must understand that a cure is usually not possible 7
Pediatric blepharokeratoconjunctivitis is often unrecognized and can be more severe, potentially leading to amblyopia 7
Carcinoma can masquerade as blepharitis, particularly with unilateral involvement 6
Medications like isotretinoin and dupilumab can induce or worsen blepharitis 3, 4
Blepharitis is a risk factor for endophthalmitis after intraocular surgery; consider addressing moderate to severe blepharitis prior to intraocular procedures 7