Blepharitis
Blepharitis - Summary
Blepharitis is inflammation of the margin of the eyelids.
Chronic blepharitis can be classified according to which part of the margin of the eyelid is affected:
Anterior blepharitis — the bases of the eyelashes (located on anterior margin of the eyelid) are inflamed.
Posterior blepharitis — the Meibomian glands (located posteriorly on the margin of the eyelid) are inflamed.
Chronic blepharitis can also be classified by its cause, as:
Staphylococcal blepharitis.
Seborrhoeic blepharitis.
Meibomian blepharitis.
Blepharitis is common and accounts for about 5% of all ophthalmological problems presenting in primary care. It is more common in older adults but can occur at any age.
Blepharitis is a chronic condition. Treatment can control symptoms and prevent complications. However, periodic remissions, relapses, and exacerbations are to be expected.
Blepharitis will not permanently damage eyesight, provided that complications affecting the eye are adequately managed.
The diagnosis of blepharitis is suggested by:
Characteristic symptoms such as itchy, burning, and sticky eyes.
The presence of conditions that can cause blepharitis e.g. rosacea and seborrhoeic dermatitis.
The presence of dry eye syndrome.
No specialist tests (e.g. swabs for culture) are usually required to investigate people with blepharitis who are being managed in primary care.
The differential diagnosis of chronic blepharitis includes squamous cell, basal cell, or sebaceous cell carcinoma of the eyelid margin, dermatitis, infection (e.g. impetigo), and infestation (pubic lice).
Management of blepharitis requires:
Assessment to determine the severity and type of blepharitis and its impact on the person.
Provision of information about the course of the illness.
Advice on good eyelid hygiene. This is the mainstay of treatment and should be carried out twice daily initially, then reduced to once daily. The person should be advised to avoid eye make-up, especially eyeliner.
Consideration of antibiotics if initial treatment is inadequate. Chloramphenicol is the first-line topical antibiotic of choice and fusidic acid is an alternative.
Referral for same-day ophthalmological assessment should be arranged if:
The person experiences sudden onset of visual loss, or
An eye becomes acutely painful and red.
Referral (with urgency appropriate to the problem) should be arranged if:
There is persistent localized disease, resistance to treatment or marked eyelid asymmetry (to exclude cancer of the eyelid margin).
There are symptoms of corneal disease (pain, blurred vision).
Vision deteriorates.
The diagnosis is uncertain.
There is associated disease, such as Sjögren's syndrome or eyelid deformities.
There is insufficient improvement despite maximal treatment available in primary care.
Have I got the right topic?
This CKS topic covers the management of chronic blepharitis.
This CKS topic does not cover acute infection of the eyelids, ulcerative blepharitis, or blepharitis caused by herpes simplex or Candida. It does not cover the wider management of conditions closely associated with blepharitis as causes or consequences, i.e. seborrhoeic dermatitis, rosacea, atopic eczema, and dry eye syndrome.
There are separate CKS topics on Dry eye syndrome, Eczema - atopic, Herpes simplex - ocular, Rosacea, and Seborrhoeic dermatitis.
The target audience for this CKS topic is health care professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.
Previous changes
April 2011 — minor update. Change to recommendation regarding need for additional contraception during or after a course of tetracycline - additional contraception is no longer required when using antibiotics that are not enzyme inducers with combined hormonal methods for durations of 3 weeks or less [FSRH, 2011]. Issued in June 2011.
March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.
September 2010 — minor update. Hydromoor® (hypromellose 0.3% preservative-free single dose eye drops) have been included. Issued in September 2010.
March 2010 — minor update. Lubri-Tears® eye ointment has been discontinued. Prescription removed. Issued in March 2010.
December 2007 to May 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
The clinical scenario structure has been reviewed.
There have been changes to the oral antibiotic prescriptions offered. Lymecycline has been added to the list of recommended tetracyclines.
Dosing recommendations for the tetracyclines have been amended; a higher initial dose is recommended for 4 weeks, followed by a lower maintenance dose for a further 8 weeks.
Prescriptions of amoxicillin and erythromycin to treat acute staphylococcal infection (cellulitis) have been removed because this indication is now outside the scope of this CKS topic. In recognition of this, the age threshold has been increased to 10 years as chronic blepharitis is very rare in young children.
January 2006 — minor update. Black triangle removed from carmellose sodium eye drops. Issued in February 2006.
October 2005 — minor technical update. Issued in November 2005.
August 2004 — reviewed. Validated in November 2004 and issued in April 2005.
August 2001 — reviewed. Validated in November 2001 and issued in April 2002.
August 1998 — rewritten.
Update
New evidence
Evidence-based guidelines
No new guidelines nice 1 September 2012.
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2012.
Systematic reviews and meta-analyses
No new systematic reviews since 1 September 2012.
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2012.
New policies
No new national policies or guidelines since 1 September 2012.
New safety alerts
No new safety alerts since 1 September 2012.
Changes in product availability
No changes in product availability since 1 September 2012.
Goals and outcome measures
Goals
To relieve discomfort and pain
To prevent or minimize complications
To provide the person with the information required for appropriate self care
Background information
Definition
What is it?
Blepharitis is inflammation of the margin of the eyelids.
Chronic blepharitis can be classified according to which part of the margin of the eyelid is affected:
Anterior blepharitis — the bases of the eyelashes (located on anterior margin of the eyelid) are inflamed.
Posterior blepharitis — the Meibomian glands (located posteriorly on the margin of the eyelid) are inflamed.
Chronic blepharitis can also be classified by its cause, as:
Staphylococcal blepharitis.
Seborrhoeic blepharitis.
Meibomian blepharitis — often called Meibomian gland dysfunction in the literature.
These types of blepharitis can occur in any combination.
In primary care, it is often difficult to distinguish among the different types — see Diagnosis.
Causes
What are the causes of blepharitis?
Blepharitis can be caused by staphylococcal infection, seborrhoeic dermatitis, meibomian gland dysfunction, or any combination of these.
Anterior blepharitis is usually caused by staphylococcal infection or seborrhoeic dermatitis of the base of the eye lashes. Rarely, it is a complication of atopic eczema [Asano-Kato et al, 2003]:
Staphylococcal blepharitis is thought to be caused by low-grade staphylococcal infection:
Staphylococcus aureus can be isolated from the eyelid margins in about 50% of people with staphylococcal blepharitis but in less than 10% of controls without blepharitis.
Staphylococcus epidermidis can be isolated from the eyelid margins in about 95% of people with staphylococcal blepharitis and in a similar proportion of controls without blepharitis.
Seborrhoeic blepharitis is closely associated with seborrhoeic dermatitis:
As with seborrhoeic dermatitis, oily secretions are increased and the affected skin is scaly, but the underlying mechanisms are not well understood.
Seborrhoeic blepharitis commonly occurs together with posterior blepharitis.
Posterior blepharitis (Meibomian blepharitis) is caused by Meibomian gland dysfunction (MGD):
The Meibomian glands run along the eyelid margin, posterior to the eyelashes; their oily secretions therefore spread onto the cornea and conjunctiva. These secretions form the outer layer of the tear film, which limits the evaporation of tears, provides a smooth optical surface, and helps maintain the structural and optical integrity of the eye.
The lipid secretions in people with MGD differ in composition and quantity from those in people with normal eyes. This explains why people with MGD often have dry eye syndrome.
Meibomian glands are derived from sebaceous glands. Seborrhoeic dermatitis and rosacea both affect the sebaceous glands. In seborrhoeic dermatitis, the sebaceous glands produce excessive secretions. In rosacea, the sebaceous glands are blocked, and fewer secretions reach the skin. This explains the association of MGD with seborrhoeic dermatitis or rosacea.
Prevalence
How common is it?
Blepharitis is common. It accounts for about 5% of all ophthalmological problems presenting in primary care (around 2–5% of GP consultations are related to eye problems) [Manners, 1997].
Blepharitis is more common in older adults but can occur at any age (see Table 1).
Table 1. Epidemiological associations with blepharitis.| Type of blepharitis | |||
|---|---|---|---|
| Staphylococcal blepharitis | More common in women | About 42 years | About 50% |
| Seborrhoeic blepharitis | Equally common in men and women | About 50 years | About 33% |
| Meibomian blepharitis | Equally common in men and women | About 50 years | 20–40% |
Prognosis
What is the prognosis?
Blepharitis is a chronic condition. Treatment can control symptoms and prevent complications. Periodic remissions, relapses, and exacerbations are to be expected.
Blepharitis will not permanently damage eyesight, provided that complications affecting the eye are adequately treated.
[American Optometric Association, 2007; American Academy of Opthalmology, 2011]
Complications
What are the complications?
Complications of blepharitis which affect the eyelids include:
Meibomian cyst (chalazion):
Painless swelling most prominent on the inside of the eyelid. The appearance is a cosmetic concern.
Due to sterile inflammation of a Meibomian gland.
Can become infected and painful (in which case it is called an infected chalazion or an internal hordeolum).
Occasionally, an upper-eyelid Meibomian cyst can press on the cornea and cause astigmatism.
Stye (external hordeolum):
Painful, purulent swelling most prominent on the outside of the eyelid.
Due to staphylococcal infection of the follicle of an eyelash.
Changes to the eyelashes in severe and long-standing cases:
Loss of eyelashes (madarosis).
Misdirection of eyelashes towards the eye (trichiasis).
Depigmentation of the eyelashes (poliosis).
Eyelid ulceration and scarring:
Can cause the eyelid to turn inwards against the eyeball (entropion) or outwards (ectropion).
Complications of blepharitis which affect the eye include:
Contact lens intolerance — common.
Dry eye syndrome (keratoconjunctivitis sicca):
Feelings of dryness, grittiness, or soreness in both eyes, which worsen throughout the day.
Watering of the eyes, particularly when exposed to wind.
See the CKS topic on Dry eye syndrome.
Conjunctivitis:
Red, injected conjunctiva.
Results from infiltration of the conjunctiva with bacterial debris from the eyelid.
Conjunctival phlyctenules:
Small (1–3 mm), hard, triangular, yellowish-white nodules surrounded by hyperaemia (dilated blood vessels).
Usually found in both eyes in the inferior limbus (the lower part of the eye where the clear cornea and white sclera meet).
Corneal inflammation (keratitis), ulceration, and scarring:
Suspect corneal inflammation or epithelial defects and refer for specialist slit-lamp examination if corneal pain and loss of visual acuity are problems. Refer urgently for same-day ophthalmological assessment if an eye becomes acutely painful and red, or if there is a rapid onset of decreased visual acuity.
Diagnosis
Diagnosis of blepharitis
History
What should I ask about blepharitis?
The diagnosis of blepharitis is suggested by:
Characteristic symptoms:
Eyelids burn, itch, and stick together.
Symptoms are worse in the mornings.
Both eyes are affected.
Symptoms are often intermittent, with exacerbations and remissions occurring over long periods.
The presence of conditions that can cause blepharitis:
Seborrhoeic dermatitis — symptoms include oily skin and dandruff. See the CKS topic on Seborrhoeic dermatitis.
Rosacea — symptoms include intermittent, prolonged facial flushing, and persistent central facial redness, with or without telangiectasia. See the CKS topic on Rosacea.
The presence of dry eye syndrome:
Symptoms of dry eye syndrome include dry, gritty eyes; blurred vision; tearing; and poor tolerance of contact lenses. See the CKS topic on Dry eye syndrome.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion in a review article [Lindsley et al, 2012].
Examination
What should I look for on examination?
In blepharitis, the margins of the eyelids are red and inflamed and may be crusted.
Additional findings and associated conditions may indicate the type of blepharitis and help guide treatment. However, blepharitis can occur in any combination of types, and clinically it is often not possible to differentiate between them. The features of the various types of blepharitis are discussed below and summarized in Table 1.
Seborrhoeic blepharitis:
Anterior margins of eyelids: erythema, oedema, and telangiectasia of the lid margins — changes are less marked than with staphylococcal blepharitis.
Eyelashes: oily skin scales; greasy crusting on the lashes.
Evidence of seborrhoeic dermatitis in other areas — flaking and greasy skin on the scalp (dandruff); behind the ears; in the external ear canal; between the eyebrows and/or along skin folds on the elbow, knee, or groin.
Staphylococcal blepharitis:
Anterior margins of eyelids: red and, in more severe cases, swollen; ulcers; scarring; telangiectasia (dilated superficial blood vessels).
Eyelashes: brittle scales of skin, which can form collarettes around the lashes; eyelashes misdirected toward the eye (trichiasis); depigmented eyelashes (poliosis); loss of eyelashes (madarosis).
Posterior blepharitis (Meibomian blepharitis):
Posterior margins of eyelids: Meibomian glands dilated, or visibly obstructed; telangiectasia; scarring.
Evidence of seborrhoeic dermatitis.
Evidence of rosacea — persistent central facial redness with or without telangiectasia, papules and/or pustules; intermittent prolonged facial flushing; nose red and bulbous (rhinophyma).
Additional information
| Feature | Posterior eyelid margin | ||
|---|---|---|---|
| Staphylococcal blepharitis | Seborrhoeic blepharitis | Meibomian blepharitis | |
| Anterior eyelid | |||
| Frequent | Rare | Unusual | |
| Frequent | Rare | May occur with long-standing disease | |
| Matted, hard scales | Oily or greasy | Excess lipids that may be foamy | |
| Occasional severe exacerbations | — | — | |
| May occur | — | Common with long-standing disease | |
| Posterior eyelid | |||
| Rare | Rare | Sometimes multiple | |
| May occur | — | — | |
| Eye | |||
| Mild to moderate injection, phlyctenules* | Mild injection | Mild to moderate injection, papillary reaction of tarsal conjunctiva | |
| Corneal epithelial defects† | Corneal epithelial defects not usually present | Corneal epithelial defects† | |
| Frequent | Frequent | Frequent | |
| Associated skin disease | |||
| Atopic eczema (rare) | Seborrhoeic dermatitis | Seborrhoeic dermatitisRosacea | |
Basis for recommendation
Basis for recommendation
This recommendation is based on expert opinion in review articles and textbooks [Frith et al, 2001; Lindsley et al, 2012].
Investigations
What diagnostic investigations should I perform?
No specialist tests (e.g. swabs for culture) are usually required to investigate people with blepharitis who are being managed in primary care.
Consider advising assessment by an eye specialist (which would include slit-lamp examination), particularly if the blepharitis is severe or resistant to treatment, or the eyes are painful or vision is blurred.
Refer urgently for same-day ophthalmological assessment if an eye becomes acutely painful and red, or if there is a rapid onset of visual loss. See Referral criteria.
Basis for recommendation
Basis for recommendation
This recommendation is based on criteria that CKS considers to be good clinical practice.
Differential diagnosis
What else might it be?
The differential diagnosis of chronic blepharitis includes:
Squamous cell, basal cell, or sebaceous cell carcinoma of the eyelid margin.
Dermatitis (e.g. contact dermatitis, atopic dermatitis).
Infection (e.g. impetigo).
Infestation (pubic lice — see the CKS topic on Pubic lice).
Basis for recommendation
Basis for recommendation
This information is based on a review article on the differential diagnosis of the swollen red eyelid [Papier et al, 2007].
Management
Management
Scenario: Management: covers the management of chronic blepharitis, including when to refer a person with blepharitis. This scenario does not cover acute infection of the eyelids, ulcerative blepharitis, or blepharitis caused by herpes simplex or Candida. It does not cover the wider management of conditions closely associated with blepharitis as causes or consequences, i.e. seborrhoeic dermatitis, rosacea, atopic eczema, and dry eye syndrome.
Scenario: Management
Scenario: Management of blepharitis
Assessment
How should I assess a person presenting with blepharitis?
If there is rapid onset of visual loss or an acutely painful red eye, refer for same-day evaluation — see Referral criteria.
Assess the severity of blepharitis and its impact on the person — severity of examination findings can correlate poorly with severity of symptoms.
Assess the type of blepharitis — see Diagnosis.
Ask about previous treatments and response.
Assess for dry eyes and other complications of blepharitis — see Complications.
Assess for associated conditions that might also need managing — see the CKS topics on:
Basis for recommendation
Basis for recommendation
These recommendations are pragmatic advice based on the pathology, complications, associated disorders, and differential diagnoses of blepharitis [American Optometric Association, 2007; Lindsley et al, 2012].
Self-care advice
What information should I give to a person with blepharitis?
Give information about the course of the illness. Explain that:
Blepharitis is a chronic or intermittent condition, and although it cannot typically be cured permanently, symptoms can usually be controlled with adequate self-care measures.
Compliance with treatment, especially eyelid hygiene, is essential, and eyelid hygiene should be continued even when the condition is well controlled.
Complications, such as eyesight loss, are rare, especially when treatment is adhered to.
For people with internet access, www.goodhope.org.uk is a useful resource, provided by the NHS, on eyelid hygiene and other aspects of blepharitis.
Basis for recommendation
Basis for recommendation
These recommendations are based on consensus opinion and reflect good clinical practice. CKS did not identify any UK guidelines on the management of blepharitis, but these recommendations are consistent with US guidelines on blepharitis and associated disorders [American Optometric Association, 2007; American Optometric Association, 2011]:
Helping people understand the chronic nature of the condition and the continuing need for treatment, particularly the practice of good eyelid hygiene (even when blepharitis is well controlled), may improve compliance.
Treatment at initial presentation
How should I treat a person with blepharitis on the first presentation?
Advise the person that good eyelid hygiene is the mainstay of treatment and should be carried out twice daily initially, then reduced to once daily. The eyelids should be cleaned in a stepwise manner:
Apply warm compresses (cloths warmed with hot water) to the closed eyelids for 5–10 minutes.
For posterior blepharitis, massage the eyelid (gently rub the eyelid margin with a circular motion) to express Meibomian glands.
Clean the eyelid — wet a cloth or cotton bud with cleanser (for example, baby shampoo diluted 1:10 with warm water) and rub along the lid margins.
Advise the person to avoid eye make-up, especially eyeliner. If this is not possible, advise the person to use an eyeliner that washes off easily.
Blepharitis frequently causes dry eye. Prescribe artificial tears or an ocular lubricant to relieve symptoms (for more information, see the CKS topic on Dry eye syndrome).
Tear replacement products include hypromellose, carbomers, polyvinyl chloride, sodium chloride, carmellose sodium, hydroxyethylcellulose, and povidone. All are available without preservatives.
Ocular lubricants (e.g. paraffins) cause blurring of vision and are not suitable for use with contact lenses, but may be helpful at night.
Consider prescribing topical antibiotics (chloramphenicol or fusidic acid) or oral antibiotics (tetracyclines) if there are clear signs of staphylococcal infection or Meibomian gland dysfunction. Antibiotics should usually be reserved for second-line use when eyelid hygiene alone has proved ineffective — see Second-line treatment.
Basis for recommendation
Basis for recommendation
Definitive treatment recommendations regarding eyelid hygiene in blepharitis cannot be made because evidence from clinical trials is limited:
Baby shampoo is probably the most widely used product for cleansing eyelids. Other products, such as sodium bicarbonate or soap, can be used, but they may be more likely to irritate the eyelid. The optimal dilution factor of baby shampoo with water is unknown, but 1:10 is often recommended as providing a good balance between irritating and cleaning actions [Denton et al, 1999].
Because eye make-up can aggravate blepharitis, experts recommend that it be avoided.
Some experts recommend use of anti-dandruff shampoos on the scalp and eyebrows, particularly if seborrhoeic dermatitis is also present [American Optometric Association, 2003].
Blepharitis, particularly posterior blepharitis (Meibomian blepharitis), is often associated with a poor-quality tear film and dry eye syndrome. Artificial tears and ocular lubricants (eye ointments) are used to relieve symptoms and prevent deterioration of the cornea [DEWS, 2007].
Recommendations on the use of topical and oral antibiotics are largely based on expert opinion, as only weak evidence from a few small clinical trials is available [American Optometric Association, 2007].
Second-line treatment
What should I do if initial treatment is inadequate?
Ask about eyelid hygiene. If this has been complied with, but is ineffective on its own, consider offering antibiotics (if not already tried):
Topical antibiotics should usually be tried first, especially if there are signs of staphylococcal infection on the anterior lid margins. A 6-week trial course is usually adequate.
Chloramphenicol eye ointment is a suitable first-line option (ointment is generally preferred to drops).
Fusidic acid eye drops are an alternative.
Consider prescribing oral tetracyclines if topical antibiotics have failed to elicit an adequate response, or if there are signs of Meibomian gland dysfunction or rosacea:
Low-dose tetracycline, oxytetracycline, lymecycline, or doxycycline is recommended.
Prescribe for a minimum of 6 weeks. However, a 3-month course will usually provide a prolonged effect.
Repeated courses are often required intermittently.
Eyelid hygiene should be maintained throughout, as this is the mainstay of treatment.
Basis for recommendation
Basis for recommendation
CKS found no relevant randomized placebo-controlled trial of a topical antibiotic for treating blepharitis. However, evidence from a small before-and-after trial and two small case series supports their use.
Chloramphenicol is the first-line topical antibiotic of choice in the UK [BNF 64, 2012]:
Chloramphenicol is one of the oldest antibiotics to be used in clinical practice. As such, controlled trials to support its effectiveness in the treatment of blepharitis are lacking. However, clinical experience over many years supports its use for this condition.
Chloramphenicol is inexpensive and is well tolerated by most people. The eye ointment formulation is usually recommended, as it stays in contact with the skin and eyelid margin longer; however, eye drops may be suitable if there is coexisting conjunctivitis.
Fusidic acid is an alternative topical antibiotic to chloramphenicol:
Fusidic acid is only available as eye drops. It may be more suitable for people who also have corneal involvement or conjunctivitis.
Ciprofloxacin is used extensively in the US [Bloom et al, 1994; Adenis et al, 1996]. However, it is usually reserved for second-line use in the UK because of concern about increasing resistance of bacteria to quinolones. The ointment formulation is currently undergoing post-marketing surveillance (black triangle) [BNF 64, 2012].
Topical ocular corticosteroids (alone or combined with topical antibiotics) are not recommended for use in primary care (unless they are prescribed following specialist assessment), as they can result in severe adverse effects, including cataracts; glaucoma; and viral, bacterial, or fungal infections involving the eyelid, conjunctiva, and cornea [Watson and Coroneo, 2001; McGhee et al, 2002; BNF 64, 2012].
CKS found no relevant randomized placebo-controlled trial of an oral tetracycline for treating blepharitis, but evidence from a small before-and-after trial and a small case series supports the use of oral tetracyclines.
The doses of tetracycline used during treatment are probably sub-therapeutic if the mechanism of action was solely that of an antibiotic. In vitro studies suggest that tetracyclines may inhibit bacterial lipases, with a subsequent reduction in free fatty acid production. Inhibition of keratinization and antimicrobial activity may also be important [Dougherty et al, 1991].
Any tetracycline can be used, but oxytetracycline or doxycycline are probably most suitable:
Oxytetracycline and tetracycline are inexpensive and only require twice-daily dosing. They should be avoided in people with renal dysfunction.
Lymecycline and doxycycline only require once-daily dosing. Both can be taken with food, which may reduce gastrointestinal intolerance and improve compliance. However:
Doxycycline should be avoided in people who are exposed to a lot of sunlight or other ultraviolet light sources.
The dose of lymecycline cannot be tapered, unlike other tetracyclines.
Referral criteria
When should I refer a person with blepharitis?
Refer for same-day ophthalmological assessment if:
The person experiences sudden onset of visual loss, or
An eye becomes acutely painful and red.
Refer with urgency appropriate to the problem if:
There is persistent localized disease, resistance to treatment or marked eyelid asymmetry (to exclude cancer of the eyelid margin).
There are symptoms of corneal disease (pain, blurred vision).
Vision deteriorates.
The diagnosis is uncertain.
There is associated disease, such as Sjögren's syndrome or eyelid deformities.
There is insufficient improvement despite maximal treatment available in primary care.
Basis for recommendation
Basis for recommendation
These recommendations are, in the absence of clinical evidence, based on what is accepted in the UK as good clinical practice.
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Artificial tears and ocular lubricants
Available artificial tears and ocular lubricants
Table 1 lists the tear replacement and ocular lubricant products available in the UK.
Table 1. Tear replacement and ocular lubricant products available in the UK.| Principal active ingredient | Products with preservatives | Products without preservatives | Comment |
|---|---|---|---|
| Hypromellose | Hypromellose (non-proprietary), Isopto Alkaline®, Isopto Plain®, Tears Naturale® | Artelac® SDUHydromoor® | 'Traditional' UK artificial tears; may require frequent application. |
| Carbomers | GelTears®, Liposic®, Liquivisc®, Viscotears® | Viscotears® (single dose) | Long acting; may require dosing only four times a day |
| Polyvinyl alcohol | Liquifilm Tears®, Sno Tears® | — | Useful when ocular surface mucin is reduced |
| Carmellose sodium | — | Celluvisc® | — |
| Hydroxyethylcellulose | — | Minims® Artificial Tears | — |
| Povidone | — | Oculotect® | — |
| Sodium chloride | — | Minims® Saline | Short-acting 'comfort drops'; useful in contact lens removal |
| Paraffin (liquid and soft, yellow) | — | Lacrilube®,Simple Eye Ointment (non-proprietary) | Ointments do not usually contain preservatives |
| Acetylcysteine* | Ilube® | — | Active mucolytic ingredient |
| Zinc sulphate | — | Zinc sulphate (non-proprietary) | An astringent; seldom used |
Choice of artificial tears and ocular lubricants
Which artificial tear or ocular lubricant should I prescribe?
The severity of the condition and the person's preference should guide the choice of artificial tears and ocular lubricants:
Mild or moderate symptoms — artificial tears alone are usually sufficient:
Hypromellose is the most commonly used product, but it requires frequent administration (at 30-minute intervals until symptoms improve, then frequency can be decreased).
Products containing carbomers or polyvinyl chloride are longer acting.
Sodium chloride is short acting and suitable as 'comfort drops' or for use with contact lenses.
If a product is used very frequently (e.g. more than six applications daily) or causes irritation, or if soft contact lenses are worn, consider switching to one that is preservative free, as these cause less irritation. Hypromellose, carbomers, polyvinyl chloride, sodium chloride, carmellose sodium, hydroxyethylcellulose, and povidone are available without preservatives.
Severe symptoms — preservative-free artificial tears are suitable (to avoid irritation caused by preservatives). Consider adding an ocular lubricant ointment for use at night.
Visible strands of mucus — consider prescribing acetylcysteine drops.
For further information on the management of dry eye syndrome, including use of conservative (self-care) measures, and for the rationale for using artificial tears and ocular lubricants, see the CKS topic on Dry eye syndrome.
Advice on artificial tears and ocular lubricants
Artificial tears control symptoms and limit damage to the eyes. A large range of products is available on prescription or over-the-counter. Advise that if an individual product proves unsuitable, another one may be tried. For further information on which product may be suitable, see Choice of artificial tears and ocular lubricants.
Eye ointments containing paraffin may be uncomfortable and blur vision; thus, they should only be used at night, and never with contact lenses.
Acetylcysteine eye drops may sting briefly.
Topical antibiotics
Choice of topical antibiotic
Which topical antibiotic should I prescribe?
Topical chloramphenicol eye ointment is preferred unless:
Other eye drops are being used concurrently (e.g. for glaucoma).
Topical chloramphenicol is contraindicated (see Prescribing topical antibiotics).
There is a coexisting disorder affecting the cornea (e.g. conjunctivitis).
The person wears contact lenses. Ideally, these should not be worn during treatment, but if the person cannot avoid wearing them, consider prescribing preservative-free chloramphenicol eye drops (some preservatives, such as benzalkonium chloride, accumulate in soft contact lenses, and may cause irritation).
If topical chloramphenicol ointment is unsuitable, consider prescribing chloramphenicol or fusidic acid eye drops. However, these may be less effective, as they will be in contact with the lid margin for less time.
Prescribing topical antibiotics
What issues should I consider before prescribing topical antibiotics?
Do not use topical chloramphenicol:
In people who have experienced myelosuppression during previous exposure to chloramphenicol.
In people who have a blood dyscrasia or who have a family history of blood dyscrasias.
Concurrently with other myelotoxic drugs.
In pregnant women (owing to the possibility of grey baby syndrome). However, it may be used in breastfeeding women [UKMiCentral, 2004].
Topical chloramphenicol is relatively well tolerated. Aplastic anaemia and bone marrow depression are very rare, and concerns about the increased risk of this adverse effect are probably unfounded [Walker et al, 1998].
People who wear contact lenses should avoid topical fusidic acid, as it contains preservatives (benzalkonium chloride).
Topical fusidic acid has no reported serious adverse effects.
Advice on topical antibiotics
What advice should I give to patients about topical antibiotics?
Give advice about applying the topical antibiotic:
Antibiotic ointment or drops should be applied after eyelid hygiene and/or at night before sleep. The frequency of application depends on the severity of the blepharitis and its response to treatment. As the condition improves, application can be reduced to once daily [American Optometric Association, 2007; American Academy of Opthalmology, 2011].
The antibiotic should be rubbed into the lid margin using a finger tip or cotton bud. As with eyelid hygiene, care should be taken not to traumatize the skin in this process [Smith and Flowers, 1995]. If an ointment is being used as recommended, it should be used sparingly, with care taken to avoid contamination of the eye.
The duration of treatment depends on the severity and response of the blepharitis. Experts recommend treating for 1 month after the inflammation has subsided, although there is no evidence from clinical trials to guide the length of treatment. If response is poor after a prolonged period (e.g. 6 weeks), the person should seek further medical advice.
Inform the person that:
Adverse effects are usually minor, such as transient stinging or a burning sensation in the eye.
Driving should be avoided if ointment causes blurred vision.
Contact lenses should be avoided where possible (if this is not possible, see Choice of topical antibiotic).
If two different eye-drop preparations are used at the same time of day, an interval of at least 5 minutes should be left between application of the two types. This will help prevent any dilution and overflow that may occur if application of one preparation immediately follows another.
Oral tetracyclines
Dosing regimen for tetracyclines
What dosing regimen of tetracyclines should I prescribe?
Tetracyclines are not specifically licensed for the treatment of blepharitis. Tetracycline and oxytetracycline are licensed for the treatment of rosacea which often accompanies chronic blepharitis; doxycycline and lymecycline are not licensed for rosacea [BNF 64, 2012].
Because evidence from controlled trials and product information are lacking, the optimal regimen of tetracyclines in the treatment of blepharitis is based on expert opinion. In general, low doses are initiated (compared with doses used for acute infections), as they are being used in an anti-inflammatory role rather than as an antibiotic. After the condition has improved noticeably (usually after 2–4 weeks), the dose can be further reduced for maintenance [American Optometric Association, 2007].
Treatment should be continued for at least 6 weeks. However, clinical experience has shown that longer courses of tetracyclines (e.g. 3 months) may provide better responses [Dart, Personal Communication, 2004].
Table 1 lists the doses of tetracyclines for the treatment of blepharitis, as recommended by CKS.
Table 1. Recommended tetracycline dosing regimen for the treatment of chronic blepharitis.| Tetracycline product | Initial dose (4 weeks) | Maintenance dose (8 weeks) |
|---|---|---|
| Tetracycline tablets | 500 mg twice a day | 250 mg twice a day |
| Oxytetracycline tablets | 500 mg twice a day | 250 mg twice a day |
| Lymecycline capsules | 408 mg once a day | 408 mg once a day* |
| Doxycycline capsules | 100 mg once a day | 50 mg once a day |
Prescribing tetracyclines
What issues should I consider before prescribing a tetracycline?
Do not use tetracyclines in:
Pregnant or breastfeeding women, or children younger than 12 years of age. Tetracyclines are deposited in the teeth and bones of the unborn or developing child.
People with renal failure, with the exception of doxycycline. Tetracycline, oxytetracycline, and lymecycline are excreted renally; doxycycline is a safer option in this group.
Avoid use of doxycycline if the person is likely to be exposed to excessive sunlight (e.g. working outdoors or on holiday in a sunny climate) or ultraviolet light from another source, owing to the risk of photosensitivity [ABPI Medicines Compendium, 2009]. Photosensitivity may also occur with tetracycline, oxytetracycline, and lymecycline, but probably to a lesser extent [Wolf, 2002].
Advice on tetracyclines
What advice should I give to patients about tetracyclines?
Advise the person to stop treatment and seek medical advice if they develop severe headache and/or visual disturbances. This may be an early symptom of benign intracranial hypertension, a rare but serious adverse effect of tetracycline-like drugs.
Inform the person that most adverse effects are not serious:
Gastrointestinal disturbances are the most common:
Nausea, vomiting, and diarrhoea are the most common symptoms.
Tetracycline and oxytetracycline should be taken on an empty stomach, which may increase nausea (in particular, milk or antacids should be avoided). Doxycycline and lymecycline may be taken with food, which may help the person tolerate the drug.
Tetracyclines can cause severe oesophagitis, presenting as a burning pain in the in the lower chest. To counteract this, recommend taking tetracyclines in an upright position with plenty of water, without chewing or breaking the tablets or capsules.
Indigestion remedies, such as antacids (or medicines containing iron or zinc), should not be taken within 2–3 hours of tetracyclines.
Advise women that:
Yeast infections, such as vulvovaginal candidiasis, may occur initially as a result of the broad-spectrum nature of tetracyclines, but this should be minimal owing to the low doses used and extended course.
Treatment of blepharitis with tetracyclines is rarely necessary in a woman of childbearing age. However, if the woman is taking oral hormonal contraception, advise her about the importance of correct contraceptive practice if she experiences vomiting or diarrhoea. For more information, see the sections on vomiting and diarrhoea in the CKS topics on Contraception - combined hormonal methods and Contraception - progestogen-only methods.
Advise people to avoid excessive exposure to sunlight and sunbeds, especially if they are taking doxycycline.
Evidence
Evidence
Supporting evidence
General treatments
Evidence on general treatments for blepharitis
Treatments for chronic blepharitis have not been well studied and are supported by limited, weak, and indirect evidence from clinical trials. Use of these treatments is thus mainly based on clinical experience and expert opinion.
CKS found no relevant randomized placebo-controlled trials of treatments (lid hygiene, topical drug treatments, oral tetracycline) for blepharitis:
Evidence of effectiveness comes from case series and small randomized controlled trials (RCTs) comparing two or more treatments. Several of the RCTs were too small to yield useful evidence on the drugs compared, but they did enable before-and-after comparisons. Such data is equivalent to evidence from a case-series study, although the titles and abstracts can lead the reader to assess the evidence as coming from RCTs.
Two of the RCTs are not reviewed here because they studied agents that are unlikely to be used in UK primary care.
Lid hygiene
Evidence on lid hygiene for chronic blepharitis
Evidence from clinical trials for the use of eyelid hygiene comes from several small case series. Because no firm conclusions can be drawn from this evidence, recommendations are based mainly on clinical experience and expert opinion.
CKS found no randomized controlled clinical trials of lid hygiene for blepharitis. Evidence of effectiveness comes from several small case series [Polack and Goodman, 1988; Avisar et al, 1991; Key, 1996; Greiner et al, 1999]. Studies of proprietary lid-cleaning products tended not to report the role of the manufacturer in funding, analysis, and reporting.
Topical antibiotics
Evidence on topical antibiotics for chronic blepharitis
Evidence that topical fusidic acid, topical ciprofloxacin, and topical tobramycin are effective in treating chronic blepharitis is provided by a small before-and-after study and data from two small randomized controlled trials (RCTs). Because no firm conclusions can be drawn from this evidence, recommendations are based mainly on clinical experience and expert opinion.
Topical fusidic acid and/or oral tetracycline:
One placebo-controlled before-and-after trial studied the response to fusidic acid gel, oxytetracycline, and fusidic acid gel combined with oxytetracycline [Seal et al, 1995]. This trial is also summarized in Oral tetracyclines:
Symptoms in people with blepharitis and associated rosacea improved in:
6 of 8 people (75%) treated with fusidic acid gel.
5 of 10 people (50%) treated with oxytetracycline.
6 of 17 people (35%) treated with fusidic acid gel combined with oxytetracycline.
Symptoms in people with chronic blepharitis of other aetiologies improved in:
0 of 10 people (0%) treated with fusidic acid gel.
3 of 12 people (25%) treated with oxytetracycline.
5 of 22 people (30%) treated with fusidic acid gel combined with oxytetracycline.
The results should be interpreted with caution:
There were only 61 participants, with 18 withdrawals (30%) and very small subgroups. The authors did not discuss the risk of bias resulting from the high withdrawal rate.
The results were not reported with confidence intervals, but with such small numbers and multiple comparisons, the confidence intervals would be very wide.
Topical ciprofloxacin and topical tobramycin:
Case series data on the effectiveness of topical ciprofloxacin and topical tobramycin for people with blepharitis or blepharoconjunctivitis is provided by a study (n = 464) which compared the two treatments [Bloom et al, 1994]:
In both groups, more than 80% were cured or improved after 7 days.
No statistically significant differences were observed between the two treatment groups.
No serious adverse-effects were observed after use of either antimicrobial agent.
These results can be extrapolated to support the use of topical antibiotics in general.
Topical ciprofloxacin and topical fusidic acid:
Case series data on the effectiveness of topical ciprofloxacin and topical fusidic acid in people with conjunctivitis or blepharitis is provided by a trial which compared the two treatments [Adenis et al, 1996]:
There were 39 participants, of whom 15 had chronic blepharitis and 1 had chronic blepharoconjunctivitis. The numbers were small, and the allocation between groups was unbalanced (5 participants were treated with ciprofloxacin and 11 were treated with fusidic acid), so reliable conclusions cannot be drawn on the comparative effectiveness of the two treatments. However, the authors concluded that both treatments are effective.
Oral tetracyclines
Evidence on oral tetracyclines for chronic blepharitis
Evidence that oral tetracyclines are effective in treating chronic blepharitis is provided by a small before-and-after study and by case-series data from a small randomized controlled trial (RCT). Because no firm conclusions can be drawn from this evidence, recommendations are based mainly on clinical experience and expert opinion.
Evidence on oral tetracycline with or without topical fusidic acid:
One before-and-after trial studied the response to fusidic acid gel, oxytetracycline, and fusidic acid gel combined with oxytetracycline [Seal et al, 1995]. This trial is also summarized in Topical antibiotics:
Symptoms in people with blepharitis and associated rosacea improved in:
6 of 8 people (75%) treated with fusidic acid gel.
5 of 10 people (50%) treated with oxytetracycline.
6 of 17 people (35%) treated with fusidic acid gel combined with oxytetracycline.
Symptoms in people with chronic blepharitis of other aetiologies improved in:
0 of 10 people (0%) treated with fusidic acid gel.
3 of 12 people (25%) treated with oxytetracycline.
5 of 22 people (30%) treated with fusidic acid gel combined with oxytetracycline.
The results should be interpreted with caution:
There were only 61 participants, with 18 withdrawals (30%) and very small subgroups. The authors did not discuss the risk of bias resulting from the high withdrawal rate.
The results were not reported with confidence intervals, but with such small numbers and multiple comparisons, the confidence intervals would be very wide.
Evidence on oral tetracycline hydrochloride and oral doxycycline:
Case series data on the effectiveness of oral tetracyclines for people with blepharitis or blepharoconjunctivitis is provided by a small trial which compared tetracycline (n = 8) with doxycycline (n = 16) in people with ocular rosacea [Frucht-Pery et al, 1993]:
All participants had improved after 12 weeks.
Symptom relief was faster in the group treated with tetracycline.
The comparison between the two groups may be subject to bias because many people refused to take tetracycline and were offered doxycycline instead.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of blepharitis.
Search dates
2008 – September 2012
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Blepharitis/, blepharit$.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
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
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
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
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
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
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
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
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)
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