A chronic disease?

The 57-year-old is getting enough. For a long time his eyes have been tormenting him, burning, occasionally tears and reddened. Encrustations are visible in the area of the eyelashes. Eye drops would not have helped. He wants to finally get rid of his complaints. What diagnosis do you think, what else is to be clarified and how can you treat the patient?

In the study, in addition to the red eyelids and scale-like encrustations, a mild conjunctival injection along the inner edge of the eyelid and yellowish plugs in this area are noted, Ophthalmologists from Bournemouth report in the British Medical Journal [1]. The patient complains of occasional blurred vision from tears and a foreign body sensation. First, he applied over-the-counter chloramphenicol eye drops, then prescribed fusidin-containing eye drops. Both helped only briefly.

Suspected diagnosis: Blepharitis

The described symptoms are the most likely to suggest blepharitis. It is an inflammation of the eyelids. It is divided into anterior blepharitis, which affects the outer lid margins, and a posterior blepharitis with involvement of the inner lid margins. While anterior blepharitis is most commonly caused by staphylococci (more common in children and young people) or seborrheic origin (more common in the elderly), posterior blepharitis develops due to impaired function of the meibomian glands with thickened secretions and constricted ducts. The result is lumps on the eyelid (meibomian cysts, hailstones) as well as dry and irritated eyes. Common is a mixed blepharitis of anterior and posterior elements, as in the case described.

What do you have to ask for??

Other symptoms of blepharitis that may need to be asked are itching, photosensitivity and eyelid nodules. In the morning, the symptoms are usually worse, often the patients wake up with glued eyes. In addition, always both eyes are reasonably affected symmetrically.

Typical findings

Not always is there such a pronounced finding as the very severe symptoms of the patients would suggest. Occasionally, the typical findings can be seen only with the slit lamp. Scaly / encrusted or foamy eyelids with superficially dilated blood vessels and yellowish plugs (clogged meibomian glands) can be observed. Sometimes you can also find hailstones (chalazia), fancy eyelashes (madarosis) and everted eyelashes (trichiasis).

differential diagnosis

Other eye diseases to be considered are conjunctivitis, corneal disorders and dry eye disease of other causes (keratoconjunctivitis sicca, Sjögren syndrome, other lacrimal glands diseases). However, the symptoms tend to increase during the day, while in the morning they are most pronounced with blepharitis. In case of unilateral or asymmetric inflammation of the eyelids, a malignant disease (sebaceous gland carcinoma, squamous cell carcinoma or basal cell carcinoma) should be considered.

treatment options

Blepharitis is a chronic disease that focuses on symptom control rather than cure. That’s what the patient needs to know. The most important measure is eyelid hygiene (see box). In staphylococcal blepharitis, broad spectrum topical antibiotics (chloramphenicol or fusidic acid) at the edges of the eyelids may be helpful. With blocked meibomian glands one can try to liquefy the secretion by warm compresses and Lidmassage and express afterwards. In chronic meibomian dysfunction, six-week systemic therapy with tetracycline (eg, oral doxycycline 100 mg, once daily) is indicated.

Lubricating eye drops and ointments help against dry eyes, and warm compresses and topical antibiotics may help against hailstones. If symptoms persist, incision and curettage may be necessary, requiring referral to an ophthalmologist. This also applies to suspected corneal inflammation, visual impairment or diagnostic uncertainty.

Apply moist, moist compresses to closed eyes at least once a day for five to ten minutes to liquefy glandular secretions.
Then carefully cleanse the eyelids with diluted baby shampoo or a cotton swab dipped in sodium bicarbonate solution (dissolve ¼ teaspoon of sodium bicarbonate in a cup of boiled, lukewarm water) or with a commercially available care kit.
The eyelid hygiene should be firmly integrated into your daily routines and carried out over a longer period to avoid recurrence.

A. M. Turnbult, M.P. Mayfield, Bournemouth Eye Unit, Bournemouth (UK): 10 Minute Consultation – Blepharitis, BMJ 2012; 344: e3328

Published in: The GP, 2013; 35 (16) page 56-57

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