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Blepharitis/Meibomitis

ROUTINE — Adnexa

Symptoms

Ocular discomfort

  • Itching, burning, and foreign body sensation.
  • Chronic tearing and mild ocular pain.

Eyelid signs

  • Redness (erythema) of the eyelid margins.
  • Crusting around the lashes upon awakening.

Timing

  • Symptoms typically worse on awakening (helps distinguish from dry eye syndrome, which often worsens later in the day).

Clinical Findings

Lid margin & lashes

  • Crusting, scurf (collarettes), and cylindrical sleeves around the lashes.
  • Cylindrical collarettes ("cylindrical dandruff"): Waxy cuffs at the lash base, pathognomonic for Demodex blepharitis.
  • Meibomian gland findings: Capped, plugged, or obstructed orifices with turbid, "toothpaste-like" secretions upon expression.
  • Telangiectasia of the posterior lid margin.

Anterior segment

  • Conjunctival injection and swollen, erythematous eyelids.
  • Superficial punctate keratitis (SPK) and mild mucous discharge.

Corneal sequelae

  • Marginal corneal infiltrates (staph hypersensitivity).
  • Corneal pannus, phlyctenules, or neovascularization (especially in rosacea).

Systemic signs

  • Rosacea: Facial telangiectasia, malar flushing, papules, or rhinophyma.
  • Seborrhea: Scalp dandruff or greasy skin.

Etiology

Anterior blepharitis (lash line)

  • Staphylococcal: Toxin-mediated inflammation; associated with collarettes and type III/IV hypersensitivity (marginal infiltrates).
  • Seborrheic: Associated with seborrheic dermatitis; characterized by greasy scurf.

Posterior blepharitis (MGD)

  • Meibomian gland dysfunction (MGD): Obstruction and altered lipid composition leading to evaporative dry eye.

Demodex blepharitis

  • Mite infestation (D. folliculorum in follicles; D. brevis in glands).
  • Diagnosis confirmed by pathognomonic cylindrical collarettes or microscopy.

Associated conditions

  • Ocular Rosacea: Strong association with MGD and corneal inflammatory signs.
  • Chalazion/Hordeolum: Acute manifestations of chronic gland obstruction or staph infection.

Red Flags

  • Unilateral, chronic, or recurrent "chalazion" at the same site: Mandates full-thickness biopsy to rule out sebaceous gland carcinoma (masquerade tumor).
  • Rosacea with corneal phlyctenules: Requires aggressive systemic intervention.
  • Staph hypersensitivity with marginal ulcers: Requires combined steroid/antibiotic therapy.
  • Refractory pediatric blepharitis: Consider Demodex as a potential cause.

Investigations

Slit-lamp exam

  • Detailed inspection of lid margins for telangiectasia, meibomian plugging, and cylindrical dandruff.
  • Evaluation of tear break-up time (TBUT) and corneal staining patterns.

Ancillary testing

  • Meibography: To quantify meibomian gland dropout or distortion.
  • Microscopy: Epilation of lashes to confirm Demodex mites if clinical suspicion is high.
  • Culture: Reserved for refractory or atypical cases to rule out resistant staph.

Treatment

Lid hygiene (cornerstone)

  • Warm compresses (5–10 min BID–QID) followed by lid massage.
  • Eyelid scrubs (commercial wipes or diluted baby shampoo) twice daily.

Topical medications

  • Antibiotics: Erythromycin ointment or azithromycin gel q.h.s.
  • Antibiotic/Steroid combinations: Tobramycin/dexamethasone BID–TID for refractory meibomitis (monitor IOP).
  • Surface inflammation: Cyclosporine or lifitegrast for associated dry eye.

Oral antibiotics

  • Doxycycline: 100 mg daily for 1–2 weeks, then tapered for 3–6 months (anti-MMP/anti-lipase effect).
  • Alternatives: Oral azithromycin or low-dose isotretinoin for refractory rosacea.

Demodex-specific therapy

  • Lotilaner 0.25% (Xdemvy) BID for 6 weeks (direct mite kill via GABA-Cl inhibition).
  • Tea tree oil: 50% weekly in-office or daily terpinen-4-ol scrubs.

Procedural options

  • Thermal pulsation (LipiFlow), Intense Pulsed Light (IPL), or manual gland expression.

Clinical Pearl

Blepharitis is a chronic condition; emphasize to the patient that treatment manages symptoms rather than providing a cure. Always biopsy unilateral refractory blepharitis to rule out sebaceous gland carcinoma. Cylindrical collarettes are pathognomonic for Demodex.

Differential Diagnosis

  • Dry eye syndrome (symptoms typically worsen later in day)
  • Pediculosis (lice)
  • Sebaceous gland carcinoma (if unilateral and refractory)
  • Contact dermatitis

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