Changes

August 2024 — reviewed. A literature search was conducted in July 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of blepharitis.
• Offer appropriate self-care advice.
• Provide pharmacological treatment when appropriate.
• Identify and refer people who need specialist management.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE Quality standards

No NICE Quality standards were found during the review of this topic.

What is it?

• Blepharitis is an inflammatory, often bilateral, condition primarily affecting eyelid margins.
• It is categorized as anterior, posterior, or mixed blepharitis. 
  • Anterior blepharitis affects the anterior lid margin and base of the lashes.
  • Posterior blepharitis affects the posterior lid margin, which contains the meibomian glands.
  • Mixed anterior and posterior blepharitis has elements of both conditions.

[AAO, 2023; BMJ, 2023; College of Optometrists, 2024a]

What causes blepharitis?

• Anterior blepharitis is usually caused by bacteria (staphylococcal blepharitis) or a seborrhoeic disorder (seborrheic blepharitis).
  • Staphylococcal blepharitis is associated with bacteria on the ocular surface. The pathophysiology is not fully understood and may involve direct bacterial infection, exotoxin hypersensitivity, or delayed cell-mediated immune hypersensitivity response. Bacteria other than staphylococci (such as Streptococci, Pseudomonas, Proprionibacterium, Corynebacteria, and Moraxella) have been identified in anterior blepharitis, supporting a theory of multifactorial aetiology. 
  • Seborrheic blepharitis is a disorder of the ciliary sebaceous glands of Zeis. Oily secretions increase, and the affected skin becomes scaly and greasy. 
• Posterior blepharitis usually results from meibomian gland dysfunction (MGD). 
  
  • The meibomian glands are sebaceous (oil-producing) glands located in the tarsal plate of the upper and lower eyelid. They produce meibum, a lipid secretion that stabilizes the tear film, slows tear evaporation, inhibits microbial contamination, and smooths the tear film to provide an even optical surface for optimal vision.
  • MGD is a chronic, diffuse abnormality of the meibomian glands characterized by terminal duct obstruction and/or changes in glandular secretion [Nelson, 2011].
  • Quantitative or qualitative deficiencies in meibum may be responsible for the symptoms of posterior blepharitis.
• Blepharitis is associated with several other conditions/risk factors, including:
  
  • Dry eye disease — present in 50% of people with staphylococcal blepharitis and 25–40% of people with seborrhoeic blepharitis and MGD. Posterior blepharitis is a leading cause of evaporative dry eye [AAO, 2023; College of Optometrists, 2024a]. 
  • Dermatological conditions — seborrhoeic dermatitis coexists with seborrheic blepharitis in up to 95% of people. Chronic blepharitis is associated with rosacea (27–51% of people), eczema, and psoriasis [Lindsley, 2012; Putnam, 2016; AAO, 2023]. 
  • Demodex mites —  Demodex infestation has been found in 30–68% of people with chronic blepharitis, especially older people. Although Demodex mites are found on healthy, asymptomatic people, it has been suggested that they may play a pathogenic role at higher densities [AAO, 2023; College of Optometrists, 2024a]. 
  • Medications — systemic medications, such as anticholinergics, antihistamines, diuretics, tricyclic antidepressants, and antipsychotics, can cause dry eye disease, which is associated with blepharitis [Craig, 2017; Jones, 2017; Akpek, 2019]. Isotretinoin is associated with a significant increase in colonization of the conjunctiva with Staphylococcus aureus, blepharitis, and a disruption in tear function [AAO, 2023]. 

[Lindsley, 2012; Putnam, 2016; BMJ, 2023; AAO, 2023; College of Optometrists, 2024a]

How common is it?

• Blepharitis is one of the most common presentations in primary eye care [College of Optometrists, 2024a].
  
  • In a US-based survey, 37% of people seen by an ophthalmologist and 47% of people seen by an optometrist had signs of blepharitis [Lemp, 2009].
  • A nationwide cohort study in South Korea found an incidence of 1.1 per 100 person-years between 2004 and 2013 [Rim, 2017].
• Blepharitis usually develops in middle age but may also occur in childhood.
  • The mean age of people with all types of blepharitis is 50 years. However, staphylococcal blepharitis is more common at a slightly younger age (mean 42 years) and affects mostly females (80%) [AAO, 2023].

What is the prognosis?

• Blepharitis is a chronic condition with periods of exacerbation and remission. A cure is generally not possible.
  • Conservative treatment (eyelid hygiene and warm compress) may facilitate symptom resolution.
  • Maintenance treatment is required to minimize the number and severity of exacerbations.
  • Serious complications are rare.

[Putnam, 2016; AAO, 2023; BMJ, 2023; College of Optometrists, 2024a]

What are the possible complications?

• Complications involving the eyelids include:
  • Meibomian cyst (chalazion). For more information, see the CKS topic on Meibomian cyst (chalazion).
  • External stye (hordeolum). For more information, see the CKS topic on Styes (hordeola).
  • Eyelash loss (madarosis), misdirection (trichiasis), or depigmentation (poliosis).
  • Eyelid thickening, ulceration, or scarring, which can cause the eyelid to turn inwards against the eyeball (entropion) or outwards (ectropion).
•  Complications involving the eyes include:
  • Contact lens intolerance.
  • Dry eye disease (keratoconjunctivitis sicca). For more information, see the CKS topic on Dry eye disease.
  • Chronic conjunctivitis. For more information, see the CKS topics on Conjunctivitis - allergic and Conjunctivitis - infective.
  • Vision loss — due to corneal inflammation (keratitis), neovascularization, or scarring. Ulceration and perforation can rarely occur and are more common in children.

[Teweldemedhin, 2017; AAO, 2023; BMJ, 2023; College of Optometrists, 2024a]

How should I diagnose blepharitis?

The diagnosis of blepharitis is usually based on history and examination. 

• Take a history.
  • Ask about the symptoms experienced. 
    
    • Symptoms of blepharitis include soreness, burning, itching, and crusting of the eyelids. 
    • Symptoms are usually bilateral and are typically worse in the morning.
    • There may be long periods of exacerbation and remission.
  • Ask about: 
    
    • Associated conditions, such as dry eye disease, seborrhoeic dermatitis, and rosacea. 
    • Exacerbating factors, such as wind, makeup, or contact lenses.
    • Previous episodes of blepharitis.
    • Previous history of eye trauma or surgery.
• Examine the eye.
  • Look for signs of blepharitis.
    • Staphylococcal blepharitis is characterized by erythema and oedema of the eyelid margin. Telangiectasia may be present on the anterior eyelid. Matted, hard scales may be seen in the eyelashes and may form collarettes that encircle the lash at the base (or further up as the lash grows). 
    • Seborrheic blepharitis has less erythema, oedema, and telangiectasia of the lid margins than staphylococcal blepharitis, with oily or greasy deposits on lashes and/or lid margins.
    • Posterior blepharitis is characterized by thick and/or opaque secretion at meibomian gland orifices. The meibomian glands may appear capped with oil, dilated, or visibly obstructed. Telangiectasias and lid scarring may be present.
    • Some people with seborrhoeic blepharitis may have features of meibomian gland dysfunction due to the dermatologic similarities between meibomian glands and epidermal sebaceous glands.
    • In all forms of blepharitis, examination of the tear film may show instability and rapid evaporation. 
    • See Table 1 for more information on features of different types of blepharitis.
  • Look for signs of:
    
    • Associated conditions, such as acne rosacea.
    • Complications, such as conjunctivitis.
    • Differential diagnoses, such as periorbital cellulitis.
  • Look for features of a serious underlying condition, such as:
    
    • A firm, warm, tender, erythematous, oedematous eyelid associated with severe pain, blurred/double vision, limited and painful eye movements, headache, fever, and malaise — suggestive of associated orbital cellulitis. 
    • Atypical clinical features, such as distortion of the eyelid margin, lash loss, ulceration, bleeding, or marked inflammation — suggestive of possible eyelid cancer.
    • Unresponsive, chronic, unilateral blepharitis (especially in older people) — suggestive of possible sebaceous gland carcinoma.
• Investigations are not routinely required but may be needed to exclude a risk factor, complication, or differential diagnosis.

Table 1. Features associated with the different types of blepharitis.

What else might it be?

• Differential diagnoses of blepharitis include:
  • Dermatological conditions, such as:
    • Psoriasis — a systemic, immune-mediated, inflammatory skin disease typically characterized by well-defined, erythematous, often scaly papules and plaques. For more information, see the CKS topic on Psoriasis.
    • Contact dermatitis — an inflammatory skin condition caused by exposure to an external irritant or allergen. For more information, see the CKS topic on Dermatitis - contact.
    • Eczema — a chronic inflammatory skin condition characterized by dry, itchy and scaly skin. For more information, see the CKS topic on Eczema - atopic.
  • Infections and infestations, such as: 
    
    • Herpes simplex eye infection — a viral infection that can cause inflammation of the retina, iris, cornea, conjunctiva, eyelids, and surrounding skin. For more information, see the CKS topic on Herpes simplex - ocular.
    • Pubic lice infestation — a parasitic infestation caused by Phthirus pubis, an obligate, blood-sucking ectoparasite. For more information, see the CKS topic on Pubic lice.
    • Impetigo — a common, superficial, and highly contagious bacterial skin infection characterized by pustules and honey-coloured crusted erosions. For more information, see the CKS topic on Impetigo.
    • Periorbital cellulitis — infection of tissues lying in front of the orbital septum (therefore, not an orbital condition). It typically presents with an acute onset of swelling, redness, and tenderness of the lids. However, it does not cause visual impairment, limited or painful eye movements, oedema of the conjunctiva, or eyeball protrusion. There may be associated fever and malaise.
    • Orbital cellulitis (rare) — infection of tissues lying behind the orbital septum (within the orbit). It presents with an acute onset of unilateral eyelid swelling, with a red and painful eye. It is often associated with severe pain, blurred or double vision, limited and painful eye movements, eyeball protrusion, headache, fever, and malaise. It is a medical emergency that can progress rapidly, potentially causing vision loss and serious complications, such as meningitis or a cerebral abscess.
  • Malignant eyelid tumours — basal cell carcinoma, squamous cell carcinoma, and melanoma are the most frequently encountered malignant tumours involving the eyelids. Sebaceous gland carcinoma is a rare and aggressive tumour most commonly found on the eyelids but can develop in any sebaceous gland.
    • Eyelid cancer should be suspected in people with atypical, unilateral, inflammatory eyelid disease that is unresponsive to treatment.
    • Features such as eyelid distortion, nodular mass, ulceration, bleeding, extensive scarring, lash loss, localized crusting and scaling of the dermis, or yellow conjunctival nodules surrounded by intense inflammation may suggest the presence of eyelid cancer. For information on the recognition and referral of suspected skin cancers, see the CKS topic on Skin cancers - recognition and referral.
    • Sebaceous cell carcinoma should be considered in people with unresponsive, chronic, unilateral blepharitis, particularly older people.

Scenario: Management of blepharitis

From age 12 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of blepharitis.

Search dates

March 2019 - July 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 15th March 2019). All results from the search were screened. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2 
S2    AB blepharitis OR TI blepharitis 
S1    (MH "Blepharitis") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
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Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

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Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.