Blepharitis: Symptoms, Causes & Treatment

Blepharitis is a chronic, multifactorial inflammatory condition of the eyelid margins representing one of the most common eye conditions seen in primary care and ophthalmology — affecting an estimated 37–47% of patients presenting to eye clinics with ocular symptoms. It affects all ages; prevalence increases with age. While rarely sight-threatening, blepharitis causes chronic ocular discomfort, recurrent acute exacerbations, and significantly impairs quality of life.

Anatomically classified into two forms: (1) Anterior blepharitis: inflammation of the anterior eyelid margin at the base of the lashes. Staphylococcal type: S. aureus and S. epidermidis overgrowth produce exotoxins causing lid margin erythema, collarette (cylindrical) crusting around lash bases, and occasional lash loss (madarosis) and misdirection (trichiasis). Seborrheic type: associated with seborrheic dermatitis (scalp/facial dandruff) — greasy scales and oily lid margins. (2) Posterior blepharitis / Meibomian Gland Dysfunction (MGD): dysfunction of the ~30 meibomian glands within each eyelid, which secrete the lipid layer of the tear film. Inspissated (thickened, turbid) meibomian secretions impair tear film stability, causing evaporative dry eye disease — the most common form of dry eye in the developed world, affecting 60–70% of blepharitis patients.

Blepharitis is a chronic relapsing condition — there is no cure. Management aims to control symptoms and prevent complications (corneal exposure, contact lens intolerance, chalazion formation) through consistent daily eyelid hygiene. Understanding the chronic nature is essential for patient adherence.

• Eyelid margin erythema (redness) and edema — bilateral, symmetric, worse in morning
• Burning, itching, and foreign body sensation in the eyes
• Crusting at lash bases: dry/hard collarettes (staphylococcal) or greasy/oily scales (seborrheic/MGD)
• Lid margin telangiectasias (fine blood vessels) and foam in the tear meniscus (MGD)
• Morning lid sticking from dried secretions
• Recurrent chalazion or hordeolum (stye) from blocked meibomian glands
• Photophobia, reflex tearing, or dry eye symptoms from unstable tear film
• In severe cases: corneal punctate epithelial erosions, marginal keratitis

• Staphylococcal overgrowth: S. aureus and coagulase-negative Staphylococci at the lid margin produce exotoxins and protease, causing anterior blepharitis
• Seborrheic dermatitis: dandruff of the scalp and eyebrows is strongly associated with seborrheic anterior blepharitis
• Meibomian gland dysfunction (MGD): obstructive or hyposecretory dysfunction of lipid-secreting meibomian glands — the primary cause of evaporative dry eye disease
• Ocular rosacea: rosacea is strongly associated with posterior blepharitis/MGD — telangiectasias and flushing of the lid margins are characteristic
• Demodex folliculorum: mite infestation of eyelash follicles — prevalent in older adults; associated with cylindrical collarette crusting; role in blepharitis pathogenesis confirmed in recent literature
• Contact lens wear: disrupts meibomian gland architecture long-term

Slit-lamp biomicroscopy: examination of lid margin (erythema, telangiectasias, lash abnormalities), meibomian gland orifices (plugging, turbid secretions on expression), and cornea (punctate staining). Tear film assessment: tear break-up time (TBUT <10 seconds = unstable), Schirmer test (aqueous deficiency), fluorescein corneal staining (epithelial erosions). Meibography: infrared imaging of meibomian gland morphology to quantify gland dropout. Epilation and microscopic examination of lashes for Demodex — cylindrical collarettes at lash base are pathognomonic.

Eyelid hygiene (cornerstone — must be consistent and lifelong): twice-daily warm compresses (45°C × 5–10 minutes — melts solidified meibomian secretions) followed by lid margin scrubs (commercial lid scrub wipes, diluted baby shampoo, or micellar water on a cotton bud) — removes bacterial biofilm and crusting. For staphylococcal blepharitis: topical antibiotic ointment (chloramphenicol, fusidic acid, azithromycin ophthalmic gel) applied to lid margins nightly for 4–6 weeks. Omega-3 fatty acid supplementation: improves meibomian gland secretion quality; 1–3 g/day fish oil or flaxseed oil for 3–6 months. Oral doxycycline or azithromycin: for moderate-severe MGD or ocular rosacea — anti-inflammatory properties beyond antibiotic activity; 6–8 week course. Demodex blepharitis: Tea Tree Oil (TTO) lid scrubs, in-office intense pulsed light (IPL) for Demodex eradication, topical ivermectin (Xdemvy). Thermal pulsation devices (LipiFlow, iLUX): in-office treatment for MGD — heat and mechanical expression of meibomian glands.

• Evaporative dry eye disease — the most common and impactful complication; significantly reduces quality of vision and ocular comfort
• Recurrent chalazion and hordeolum from chronic meibomian gland obstruction
• Marginal keratitis and corneal vascularization in severe staphylococcal blepharitis
• Lash abnormalities: madarosis (lash loss), poliosis (lash whitening), trichiasis (misdirected lashes abrading cornea)

• Daily eyelid hygiene even during remissions — the most effective prevention of recurrence; blepharitis is chronic and returns without maintenance
• Treatment of seborrheic dermatitis of the scalp and face reduces seborrheic blepharitis exacerbations
• Omega-3 supplementation as ongoing preventive maintenance for MGD
• Avoid eye makeup that may block meibomian gland orifices (waterproof mascara, eyeliner on the waterline)