AKT · Ophthalmology/Lids & surface

Blepharitis

Chronic lid-margin inflammation (anterior: staph/seborrhoeic; posterior: meibomian gland dysfunction)

Overview

Chronic inflammation of the eyelid margins. Anterior blepharitis affects the lash bases (staphylococcal or seborrhoeic); posterior blepharitis is meibomian gland dysfunction (MGD), strongly linked to rosacea and seborrhoeic dermatitis. Bilateral, relapsing-remitting gritty sore eyes — a clinical diagnosis managed conservatively, NOT with antibiotics first-line.

Recognise

Bilateral burning, grittiness, itching and crusting of the lid margins, worse on waking
Anterior: scales/collarettes at the lash bases, lashes may be lost or misdirected (trichiasis)
Posterior (MGD): capped/inspissated meibomian orifices, frothy tear film, oily tear instability
Associations: rosacea, seborrhoeic dermatitis, dry eye, recurrent chalazia/styes

Red flags

Pain, photophobia or blurred/reduced vision → corneal involvement (marginal keratitis) — same-day ophthalmology
Unilateral, ulcerated or non-resolving lid lesion with lash loss → consider eyelid malignancy (BCC/sebaceous) — 2-week-wait

Differentials & how to tell them apart

Bacterial conjunctivitispurulent discharge with conjunctival (not lid-margin) injection; blepharitis is lid-margin scaling without true discharge

Dry eye diseaseoverlaps and coexists; dry eye is tear-film deficiency without lid-margin crusting/collarettes

Sebaceous gland carcinomaunilateral recurrent 'chalazion' with madarosis (lash loss) — biopsy a recurrent unilateral lesion

Allergic eye diseaseitch-dominant with chemosis and a personal/atopic history

Blepharitis — crusting and inflammation of the lid margins
clubtable / Public domain — Wikimedia Commons

Investigations

Clinical (lid-margin examination at the slit lamp). No routine investigation. Swab only if severe/atypical or unresponsive.

Management

Lid hygiene — warm compresses + lid-margin cleaning (and eyelid massage for posterior/MGD)

1Lid hygiene twice daily (warm compress 5–10 min, then lid-margin cleaning; add eyelid massage to express meibomian glands in posterior disease). Explain it is chronic and needs ongoing maintenance even when settled. Treat associated dry eye, seborrhoeic dermatitis or rosacea.Gate: Arrange EMERGENCY admission if periorbital/orbital cellulitis; same-day ophthalmology if pain, photophobia, red eye or visual loss (corneal disease) — do NOT just treat as lid disease
2Anterior, lid hygiene ineffective → topical chloramphenicol rubbed into the lid margin. Posterior with rosacea/MGD → oral doxycycline (off-label) or tetracycline (avoid in pregnancy/under-12s → erythromycin). Refer if diagnosis uncertain or vision deteriorating.

Lid hygiene (warm compress + lid-margin cleaning) — the mainstay — diluted baby shampoo/sodium bicarbonate or commercial lid wipes, twice daily then once daily

Topical chloramphenicol (ointment to lid margin) — anterior blepharitis not responding to lid hygiene — rub into the lid margin

Oral doxycycline / tetracycline — posterior blepharitis (MGD) with rosacea; anti-inflammatory dose. CONTRAINDICATED in pregnancy/lactation/children <12 — use erythromycin

Ocular lubricants — for associated dry eye symptoms

Key points

It is chronic and relapsing — the teaching point is maintenance lid hygiene, not a course of antibiotics. A recurrent unilateral 'chalazion' with lash loss is sebaceous carcinoma until proven otherwise.

Monitor & prognosis

Review symptom control; reinforce that stopping lid hygiene causes relapse.

Good symptom control with adherence; not curable but controllable.

Source: NICE CKS Blepharitis (College of Optometrists CMG; BOPSS)