Ophthalmology presentation, Eye clinic residency teachings, blepharitis, nasolacrimal duct obstruction, medical residency programmes, Ear nose and throat, dacryocystitis, lacrimal sac tumors, lacrimal sac drainage, nasolacrimal duct nursing care, dacrocystorhinostomy, endoscopic DCR, Eye lid inflammation, anatomy of the eye lid, punctum, canaliculi, tear drainage channel, infections of the eye lid, criggler's massage

1. BLEPHARITIS
PRESENTED
BY
DR. AVURU CHUKWUNALU JAMES

2. OUTLINE
• INTRODUCTION/DEEFINITION
• Brief Anatomy of eyelid margin
• Classification
• Epidemiology
• Pathophysiilogy
• Risk factirs
• Management
• Prognosis
• Conclusion

3. INTRODUCTION/DEFINITION
• Blepharitis is an inflammatory condition of the
eyelid margin
• common cause of ocular discomfort and irritation
in all age and ethnic groups
• generally not sight-threatening, but can lead to
permanent alterations in the eyelid margin or
vision loss

4. BRIEF ANATOMY OF THE LID
MARGIN
• It is about 2mm broad and divided into 2 parts by the
punctum(medial and lateral)
• Lacrimal portion(medial)- is devoid of lashes
• Ciliary portion (lateral)- consists of rounded anterior border
and sharp posterior border with an intermarginal strip
between them (the 2 borders)
• The grey line divides the intermarginal strip into
• Anterior strip bearing 2-3 rows of lashes
• Posterior strip on which openings of the meibomian
glands are arranged in a row
• SPLITTING OF THE EYELID IS DONE AT THE GREY LINE IN
SURGERIES

6. classification
anatomy
1). anteerior blepharitis....
2). posterior blepharitis

7. anterior blepharitis
• Inflammation involving the area surrounding the
bases of the eyelashes
• skin
• eyelashes,
• Eye lash follicles

8. ANTERIOR BLEPHARITIS
• staphylococcal
• seborrheic

9. • staphylococcal blepharitis may be an abnormal cell-
mediated response to components of the cell wall
of S. aureus, which may also be responsible for the
red eyes and peripheral corneal infiltrates
• More common and marked in patients with atopic
dermatitis.
• Seborrhoeic blepharitis is strongly associated with
generalized seborrhoeic dermatitis that
characteristically involves the scalp, nasolabial
folds, skin behind the ears and the sternum.

10. posterior blepharitis
• meibomian gland orifices,
• meibomian glands,
• tarsal plate,
• blepharo-conjunctival junction

11. EPIDEMIOLOGY
• FREQUECY; Common eye disorder worldwide. 86% of
patient with dry eye have concomitant blepharitis
• Mortality/Morbidity; loss of visual function, well-being,
and ability to carry out daily life activities.
• lids with trichiasis, notching, entropion, and
ectropion.
• Corneal scaring, irregularity(astigmatism),
perforation
• mortality, such as in systemic lupus erythematosus,
may have blepharitis as part of their constellation of
findings

12. Epidemiology; Race
• No known studies demonstrate racial differences in
the incidence, of blepharitis, although Rosacea may
be more common in fair-skinned individuals

13. EPIDEMIOLOGY contd
• SEX:
• no difference in incidence
• Age
• Seborrheic blepharitis is more common in an older
age group. The apparent mean age is 50 years.

14. Pathophysiology
. The exact pathogenesis of blepharitis is unknown,
but suspected to be multifactorial.
. bacterial colonizes the eyelids.
. direct microbial invasion of tissues, immune
system–mediated damage, or damage caused by the
production of bacterial toxins, waste products, and
enzymes.
. Colonization of the lid margin is increased in the
presence of seborrheic dermatitis or meibomian
gland dysfunction

15. PATHOPHYSIOLOGY CONTD
• Meibomian gland dysfunction
• functional abnormalities of the meibomian
glands and altered secretion of meibum (slows
evaporation of tear film and smoothing the tear
film to provide an even optical surfa)
• Both quantitative and quantitative deficiencies in
meibum contributes to symptoms in MGD
blepharitis.

16. PATHOPHYSIOLOGY CONTD
• Bacterial lipases may result in the formation of free fatty acids.
This increases the melting point of the meibum, preventing its
expression from the glands, contributing to ocular surface
irritation and possibly enabling growth of S.
• MGD leads to meibomian waxlike secretions and blockage of
gland orificees
• Stagnant material becomes a growth medium for bacteria
• deeper eyelid tissue layers become affected causing
inflammation.
• Leads to M gland plugging, inspissated lipid secretory material,
inflamed orifices, and formation of hordeola and chalazia.

17. RISK FACTORS
• Dry Eye
• present in 50% of patients with staphylococcal
blepharitis. ; a decrease in local lysozyme and
immunoglobulin levels associated with tear deficiency
may alter resistance to bacteria, predisposing patients
to the development of staphylococcal
• 25% to 40% of patients with seborrheic blepharitis and
MGD also have dry eye.; may result from increased
tear film evaporation due to a deficiency in the lipid
component of the tears as well as reduced ocular
surface sensation.[4]

18. RISK FACTORS-DERMATOLOGICAL
CONDITIONS
• Acne rosacea
• has been reported in 20% to 42% of patients with
all types of blepharitis
• Characterized by facial skin erythema,
telangiectasias, papules, pustules, and prominent
sebaceous glands.
• Seborrheic dermatitis, characterized by flaking and
greasy skin on the scalp, retroauricular area,
glabella, and nasolabial folds,--reported in 33% to
46% of patients with blepharitis

19. RISK FACTORS
CONTD;Demodicosis
• Demodex infestation;
• characterized by cylindrical dandruff or sleeves around
the eyelashes
• found in 30% of patients with chronic blepharitis.
• Infestation and waste of the mites causes
• blockage of the follicles and glands
• inflammatory response
• Demodex folliculorum longus in anterior blepharitis
and Demodex folliculorum brevis in posterior
blepharitis

20. Rosacea

21. • Posterior blepharitis is commonly more persistent
and chronic inflammatory condition than anterior
blepharitis; there is an association with acne
rosacea.

22. SUMMARY OF CAUSES
• Rosacea
• Herpes simplex dermatits
• Variccella-zoster dermatits
• molluscum contagiosum
• Allrgic/contact dermatitis
• Seborrheic dermatitis
• Pasites llike Demodex and Phthiriasis palpabrarum
• staphylococcal dermatitis
• Chronic blepharitis: exposuure tochemical fumes, smoke, smog
etc
• Acutee blepharitis ; allergy, drug toxiccity, cheemical reaction
• Sjogren syndrome

23. COMPLICATIONS
• Conjunctivitis
• Keratitis
• Cataract, glaucoma, reactivation of viral infections
due to use of steroids
• Trichiasis, Ectropion and entropion

24. MANAGEMENT
• HISTORY
• EXAMINATION
• INVESTIGATIONS
• TREATMENT

25. HISTORY
• AGE; MORE IN ADULTS: AVERAGE AGE OF 50YRS
• Eye irritation, itching, and flaking of the lid
• burning sensation, Eye Watering, Foreign body
sensation
• Gumming of the lid lashes
• Red lids, Red eyes, Photophobia, Pain
• Decreased vision, Visual fluctuations

26. HISTORY CONTD
• Long duuration of symptoms with intermittent
exacerbations
• scalp itching, flaking, and oily skin. seen in seborrheic
dermatitis
• red and swollen nose (rhinophyma), facial flushing,
pustules, oily skin, food and environmental intolerances,
and eye irritation seen in Rosacea
• chronic irritation and itching of the lids in phthiriasis
palpebrarum
• Symptoms are worse in the mornings although in patients
with associated dry eye the ymay increase during the
day

27. PHYSICAL EXAMINATTION
• External eye examination;
• erythema and vesicle formation over thhe skin in
Herpetic skin disease
• oily skin and flaking from the scalp or brows in
Seborrheic dermatitis
• pustules, rhinophyma, telangiectasias of the
cheeks and eyelid margins, erythema seen iin
rosacea

28. EXAMINATION CONTD-ocular
• Pentorch exam may show erythema and crusting
of the lashes and lid margins.
• VISUAL ACUITY; Normal or reduced

29. Associations/Definitions
• Crusting ; flakes of material that adhere to the
lashes(seborrheic disease.)
• SCURF; epithelial materials around the lashes
• collarette ; iirregular ringlike formation around the
lash shaft (staphylococcal blepharitis)
• sleeve ; smooth tube of material that surrounds the
base of the lash as it intersects the lid(Demodex)

30. ANTERIOR BLEPHARITIS CONTD
• Ulcers ; at the base of the lashes. They are covered
by a crust of fibrin which is lifted up as the lash
shaft grows
• Corneal disease is most common with the
staphylococcal blepharitis

32. OCULAR EXAMINATION CONTD
• LID EXAMMINATION ; loss of lashes (madarosis),
• whitening of the lashes (poliosis),
• lid scarring and misdirection of lashes (trichiasis),
• crusting of the lashes and meibomian orifices,
• eyelid margin ulceration,
• plugging and "pouting" of the meibomian orifices,
• telangiectasias of the lid margin,
• lid irregularity (tylosis).

34. • Demodex infestation may lead to cylindrical
dandruff-like scaling (collarettes) around the base
of eyelashes
• mites can be demonstrated under ×16 slit lamp
magnification

36. • eyelids (phthiriasis palpebrarum). A crab louse
• Lice are readily visible anchored to lashes
• lice have six legs rather than the eight
possessed by ticks

38. • Red, scaly, macerated and fissured skin seen at
the lateral and/or medial canthi of one or both
eyes(Angular blepharitis caused by Moraxella
lacunata or S. aureus
• NB: other bacteria, and rarely herpes simplex
can cause angular blepharitis

40. OCULAR EXAM CONTD
• conjunctiva may show
• papillary injection.
• tarsal thickening
• loss of normal tarsal vascular architecture,
• subconjunctival substantia propria fibrosis,
• conjunctival scarring,
• tarsal distortion due to cicatricial contraction which
may llead to subsequent entropion.

41. OCULAR EXAMINATION CONTD
• Corneal MAY SHOW
• punctate epithelial erosions,
• marginal infiltrates,
• marginal ulcers,
• limbal inflammation and thickening (limbitis),
• peripheral corneal ectasia, pannus, and phlyctenule
formation.

42. • Salzmann nodular degeneration may occur
• corneal lesions are commonly at the limbus at 2-,
4-, 8-, and 10-o'clock positions. where the upper
and lower lid margins crosses thee limbus
• Corneal infiltrates , then keratittis and perforation
may occuur

46. INVESTIGATIONS
• Diagnosis is clinical. However,
• eyelid margin cultures,
• transillumination studies of the meibomian glands,
• digital-imaging techniques,
• conjunctival impression cytology,
• marginal biopsies,
• analysis of gland secretions.

47. Investigations contd
• Tests for tear insufficiency
• Nasolacrimal gland drainage pathology
• Histology
• Imaging Studies

48. Histology
• Seborrrheic dermatitis; spongiosis, mild
perivascular, lymphohistiocytic, mononuclear
cellular infiltrates in the superficial dermis.
• Staphylococcal blepharitis ; nongranulomatous
inflammation, usually with neutrophils and, often,
acanthosis or parakeratosis

49. IMAGING STUDY
• CT SCAN
• MRI
• The LipiView (Tear Science) allows visualization of each
individual meibomian gland in the everted inferior
tarsal plate, permits
• a semi-quantitative analysis of meibomian
gland viability.
• measure incomplete blink rate and the
thickness of the lipid oil tear layer in nanometers.
• Keratograph 5M (Oculus); functions like lipiview

50. TREATMENT
• Blepharitis is a chronic condition with frequent
exacerbation.
• Currently, standard therapy is directed at control of
symptoms and inflammatory signs

51. general treament
• Eyelid hygiene
• WARM compress; several minuts 2-4times daily
• Eye lid masssage; esp vertical lid masssage
• Eye lid scrubs
• These softens adherent scurf and scales
• warm the meibomian secretions.
• Express meibomian secretions.

52. • When substantial meibomian gland disease is
present, the regimen may include
• expression of accumulated meibum by rolling
the finger anteriorly over the margin.
• The putative action of lid hygiene against
Demodex is via prevention of reproduction
• mechanical removal of the lice and their
attached lashes with fine forceps

54. Antibiotic ointment
• Applied to the eyelid margin after soakS and scrubS
• Topical sodium fusidic acid, bacitracin, polymyxin
B, erythromycin, or sulfacetamide ointments are
commonly used
• Following lid hygiene the ointment should be
rubbed onto the anterior lid margin
• Antibiotic-corticosteroid ointment combinations
can be used for short courses

55. ANTIBIOTIC
• Oral antibiotics( one to two months course)
• such as tetracyclines, macrolides; Recommended in
• MGD not controlled with eyelid hygiene
• Rosacea
• Treatment tailored to response,
• Tetracyycline improves symptoms in patients with ocular
rosacea
• improves tear break-up time in patients with rosacea and
MGD
• side effects; pregnant or nursing women, children under 10
years of age(tetraccycline). azithhromyycin(arrhythmia)

56. • doxycycline (50–100mg twice daily for 1 week and then
daily for 6–24 weeks),
• Azithromycin (500 mg daily for 3 days for three cycles at
1-week intervals)
• Tetracyclines- more effective in the treatment of posterior
disease,
• azithromycin more effective in anterior blepharitis
• Erythromycin 250 mg once or twice daily is an alternative.
• topical yellow mercuric oxide 1% or petroleum jelly can be
applied to the lashes and lids twice a day for 10 days in
Lash louse

57. Steroids
• Topical steroids;
• Beneficial for symptomatic relief
• inflammation reduction
• Corticosteroid drops or ointment applied several times daily
• A short course, tepered off and reintrduced as needed
• loteprednol etabonate,, Fluorometholone
• Stroida side effect; increase IOP, cataract formation
• Topical combinations of an antibiotic and corticosteroid
such as tobramycin/dexamethasone or
tobramycin/loteprednol exists

58. IMMUNE MODULATORS
• Reduuces iinflammation
• topical cyclosporine 0.05% was shown to result in
significantly greater improvement in eyelid margin
inflammatory signs than the comparator group:
artificial tears or tobramycin/dexamethasone
ophthalmic suspension.

59. Topical Lubrication
• artificial tears used combined with eyelid
cleansing and other medications
• Important in evaporative and aqueous tear
deficiency,
• preservative-free tears are better used to avoid
toxicity esp if applied more than qds

60. Surgical treatment
• needed for complications such as
• chalazion formation,
• trichiasis,
• ectropion, entropion,
• corneal disease

61. NEW THERAPIES
• Thermal pulsation therapy;
• LipiFlow device (Tear Science) ;homogenous
temperature of 40.5 degrees C applied tto thhe eyelid
and expresses infected, inspissated and dead debris
from the meibomian glands
• MiBoFlo (thermal therapy)
• BlephEx
• The Maskin probe; fine stainless-steel tip applied to the
thoroughly anesthetized inspissated meibomian gland
orifice, light electrical current is applied to facilitate the
flow of meibum

62. ADJUNCT MGT
• Inccreease intake of Omega-3 faty acids(recommended by the
International Workshop on MGD for cases of mild-to-severe
MGD)
• Reduuces inflammation
• reduced dry eye symptoms.
• Demodex infestation; in failed convennional treatment
methods
• 50% tea-tree oil eyelid scrubs and daily tea-tree-oil
shampoo scrubs(minimum of 6weeks use)
• Topical permethrin and topical (1% cream) or oral
(two doses of 200 µg/kg 1 week apart) ivermectin
recalcitrant cases)

63. Follow up
• Treat and folow up in 2-6 weeks for examination
• Counsel on the need for adherence to
treatment(usuall prolonged)
• Fluorescein staining of the cornea is recommended
on each examination.

64. Consultations
• Co--management with dermatologists in presence
of dermatitis

65. Prognosis
• Blepharitis is a chronic condition that has periods of
exacerbation and remission
• Adequate counselling importtant(symptom can
frequently be improved but are rarely eliminated
• rarely peermanent complcations can arise in severe
cases( e.g eelid margin deforrmiity, ccornea scaring,
neovascularization or perforation)
• Malignancy should e ruled out in suspicious cases

66. Conclusion
• Blepharitis is a chronic condition
• Mgt requires commitment from both the patient
and managing ophthalmologist
• Adequate counselling and timely intervention is
important

67. THANK YOU