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Roni M Shtein, MD
Section Editor
Jonathan Trobe, MD
Deputy Editor
Howard Libman, MD, FACP


Blepharitis is a common chronic ophthalmologic condition characterized by inflammation of the eyelid margin associated with eye irritation. Other related eyelid conditions are discussed separately, as is dry eye disease, which is a frequent complication of blepharitis. (See "Eyelid lesions" and "Dry eyes".)


The etiology and pathophysiology of blepharitis differ somewhat based on the type (posterior versus anterior). However, there is considerable overlap between these categories (table 1) [1].

Posterior blepharitis – Posterior blepharitis, the more common type, is characterized by inflammation of the inner portion of the eyelid at the level of the Meibomian glands (picture 1) [2]. Meibomian glands are modified sebaceous glands located within the tarsal plates of the eyelids responsible for secretion of the oily layer of the tear film. This oily layer prevents tear evaporation, reduces the surface tension of the tear layer, and facilitates the spread of tears [3]. It is critical for normal eye lubrication.

Hyperkeratinization of the meibomian gland ductal epithelium is an early finding in patients with posterior blepharitis [4]. Altered lipid composition in gland secretions leads to instability of the tear film [5-11]. The abnormal secretions also have a direct toxic effect on the ocular surface [8,12]. Additionally, the altered lipid composition provides an environment that promotes bacterial growth, which perpetuates the Meibomian gland abnormalities. Long-term inflammation leads to gland dysfunction and fibrosis as well as damage to the eyelid and ocular surface.

Chronic inflammatory skin conditions such as rosacea and seborrheic dermatitis may cause posterior blepharitis, but it also commonly occurs in their absence [3,13,14]. Blepharitis in patients with underlying chronic dermatoses tends to be more severe. (See "Seborrheic dermatitis in adolescents and adults".)

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Literature review current through: Nov 2017. | This topic last updated: Jul 21, 2017.
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  1. Duncan K, Jeng BH. Medical management of blepharitis. Curr Opin Ophthalmol 2015; 26:289.
  2. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci 2011; 52:1922.
  3. Driver PJ, Lemp MA. Meibomian gland dysfunction. Surv Ophthalmol 1996; 40:343.
  4. Gutgesell VJ, Stern GA, Hood CI. Histopathology of meibomian gland dysfunction. Am J Ophthalmol 1982; 94:383.
  5. McCulley JP, Dougherty JM, Deneau DG. Classification of chronic blepharitis. Ophthalmology 1982; 89:1173.
  6. McCulley JP, Dougherty JM. Blepharitis associated with acne rosacea and seborrheic dermatitis. Int Ophthalmol Clin 1985; 25:159.
  7. Shine WE, McCulley JP. Meibomian gland triglyceride fatty acid differences in chronic blepharitis patients. Cornea 1996; 15:340.
  8. Dougherty JM, McCulley JP. Analysis of the free fatty acid component of meibomian secretions in chronic blepharitis. Invest Ophthalmol Vis Sci 1986; 27:52.
  9. Shine WE, McCulley JP. Polar lipids in human meibomian gland secretions. Curr Eye Res 2003; 26:89.
  10. Shine WE, McCulley JP. Meibomianitis: polar lipid abnormalities. Cornea 2004; 23:781.
  11. Baudouin C. The pathology of dry eye. Surv Ophthalmol 2001; 45 Suppl 2:S211.
  12. Smith RE, Flowers CW Jr. Chronic blepharitis: a review. CLAO J 1995; 21:200.
  13. Burton JL, Pye RJ, Meyrick G, Shuster S. The sebum excretion rate in rosacea. Br J Dermatol 1975; 92:541.
  14. Karalezli A, Borazan M, Dursun R, et al. Impression cytology and ocular surface characteristics in patients with seborrhoeic dermatitis. Acta Ophthalmol 2011; 89:e137.
  15. McCulley JP, Dougherty JM. Bacterial aspects of chronic blepharitis. Trans Ophthalmol Soc U K 1986; 105 ( Pt 3):314.
  16. Groden LR, Murphy B, Rodnite J, Genvert GI. Lid flora in blepharitis. Cornea 1991; 10:50.
  17. Dougherty JM, McCulley JP. Comparative bacteriology of chronic blepharitis. Br J Ophthalmol 1984; 68:524.
  18. McCulley JP, Shine WE. The lipid layer of tears: dependent on meibomian gland function. Exp Eye Res 2004; 78:361.
  19. Dougherty JM, McCulley JP. Bacterial lipases and chronic blepharitis. Invest Ophthalmol Vis Sci 1986; 27:486.
  20. Thygeson, P. The etiology and treatment of blepharitis: a study in military personnel. Arch Ophthalmol 1946; 98:191.
  21. Raskin EM, Speaker MG, Laibson PR. Blepharitis. Infect Dis Clin North Am 1992; 6:777.
  22. Roth AM. Demodex folliculorum in hair follicles of eyelid skin. Ann Ophthalmol 1979; 11:37.
  23. Kemal M, Sümer Z, Toker MI, et al. The Prevalence of Demodex folliculorum in blepharitis patients and the normal population. Ophthalmic Epidemiol 2005; 12:287.
  24. American Academy of Ophthalmology. Blepharitis: Preferred Practice Pattern. Available at: https://www.aao.org/preferred-practice-pattern/blepharitis-ppp--2013 (Accessed on June 01, 2017).
  25. Bowman RW, Dougherty JM, McCulley JP. Chronic blepharitis and dry eyes. Int Ophthalmol Clin 1987; 27:27.
  26. Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunctivitis in children: diagnosis and treatment. Br J Ophthalmol 2005; 89:400.
  27. Doan S, Gabison EE, Nghiem-Buffet S, et al. Long-term visual outcome of childhood blepharokeratoconjunctivitis. Am J Ophthalmol 2007; 143:528.
  28. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. Invest Ophthalmol Vis Sci 2005; 46:3089.
  29. Gilbard JP. Dry eye, blepharitis and chronic eye irritation: divide and conquer. J Ophthalmic Nurs Technol 1999; 18:109.
  30. Smolin G, Okumoto M. Staphylococcal blepharitis. Arch Ophthalmol 1977; 95:812.
  31. Mondino BJ. Inflammatory diseases of the peripheral cornea. Ophthalmology 1988; 95:463.
  32. Arita R, Suehiro J, Haraguchi T, et al. Objective image analysis of the meibomian gland area. Br J Ophthalmol 2014; 98:746.
  33. Liang Q, Pan Z, Zhou M, et al. Evaluation of Optical Coherence Tomography Meibography in Patients With Obstructive Meibomian Gland Dysfunction. Cornea 2015; 34:1193.
  34. Abdelfattah NS, Dastiridou A, Sadda SR, Lee OL. Noninvasive Imaging of Tear Film Dynamics in Eyes With Ocular Surface Disease. Cornea 2015; 34 Suppl 10:S48.
  35. Brownstein S, Codere F, Jackson WB. Masquerade syndrome. Ophthalmology 1980; 87:259.
  36. Akpek EK, Polcharoen W, Chan R, Foster CS. Ocular surface neoplasia masquerading as chronic blepharoconjunctivitis. Cornea 1999; 18:282.
  37. Kass LG, Hornblass A. Sebaceous carcinoma of the ocular adnexa. Surv Ophthalmol 1989; 33:477.
  38. Shields JA, Demirci H, Marr BP, et al. Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology 2004; 111:2151.
  39. Lindsley K, Matsumura S, Hatef E, Akpek EK. Interventions for chronic blepharitis. Cochrane Database Syst Rev 2012; :CD005556.
  40. Holzchuh FG, Hida RY, Moscovici BK, et al. Clinical treatment of ocular Demodex folliculorum by systemic ivermectin. Am J Ophthalmol 2011; 151:1030.
  41. Kheirkhah A, Casas V, Li W, et al. Corneal manifestations of ocular demodex infestation. Am J Ophthalmol 2007; 143:743.
  42. Polack FM, Goodman DF. Experience with a new detergent lid scrub in the management of chronic blepharitis. Arch Ophthalmol 1988; 106:719.
  43. Key JE. A comparative study of eyelid cleaning regimens in chronic blepharitis. CLAO J 1996; 22:209.
  44. Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther 2008; 25:858.
  45. Foulks GN, Borchman D, Yappert M, Kakar S. Topical azithromycin and oral doxycycline therapy of meibomian gland dysfunction: a comparative clinical and spectroscopic pilot study. Cornea 2013; 32:44.
  46. Liu Y, Kam WR, Ding J, Sullivan DA. Effect of azithromycin on lipid accumulation in immortalized human meibomian gland epithelial cells. JAMA Ophthalmol 2014; 132:226.
  47. Wladis EJ, Bradley EA, Bilyk JR, et al. Oral Antibiotics for Meibomian Gland-Related Ocular Surface Disease: A Report by the American Academy of Ophthalmology. Ophthalmology 2016; 123:492.
  48. Ta CN, Shine WE, McCulley JP, et al. Effects of minocycline on the ocular flora of patients with acne rosacea or seborrheic blepharitis. Cornea 2003; 22:545.
  49. Cullen SI, Crounse RG. Cutaneous pharmacology of the tetracyclines. J Invest Dermatol 1965; 45:263.
  50. Mates A. Inhibition by tetracycline in the occurrence of extracellular lipase from Staphylococcus aureus. Microbios 1973; 7:25.
  51. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The role of tetracycline in chronic blepharitis. Inhibition of lipase production in staphylococci. Invest Ophthalmol Vis Sci 1991; 32:2970.
  52. Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani P. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol 1993; 116:88.
  53. Iovieno A, Lambiase A, Micera A, et al. In vivo characterization of doxycycline effects on tear metalloproteinases in patients with chronic blepharitis. Eur J Ophthalmol 2009; 19:708.
  54. Torkildsen GL, Cockrum P, Meier E, et al. Evaluation of clinical efficacy and safety of tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05% compared to azithromycin ophthalmic solution 1% in the treatment of moderate to severe acute blepharitis/blepharoconjunctivitis. Curr Med Res Opin 2011; 27:171.
  55. Lee H, Chung B, Kim KS, et al. Effects of topical loteprednol etabonate on tear cytokines and clinical outcomes in moderate and severe meibomian gland dysfunction: randomized clinical trial. Am J Ophthalmol 2014; 158:1172.
  56. Rubin M, Rao SN. Efficacy of topical cyclosporin 0.05% in the treatment of posterior blepharitis. J Ocul Pharmacol Ther 2006; 22:47.
  57. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea 2006; 25:171.
  58. Prabhasawat P, Tesavibul N, Mahawong W. A randomized double-masked study of 0.05% cyclosporine ophthalmic emulsion in the treatment of meibomian gland dysfunction. Cornea 2012; 31:1386.
  59. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 2012; 31:396.
  60. Blackie CA, Coleman CA, Holland EJ. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol 2016; 10:1385.
  61. Bilkhu PS, Naroo SA, Wolffsohn JS. Randomised masked clinical trial of the MGDRx EyeBag for the treatment of meibomian gland dysfunction-related evaporative dry eye. Br J Ophthalmol 2014; 98:1707.
  62. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg 2015; 33:41.
  63. Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2015; 56:1965.
  64. Vegunta S, Patel D, Shen JF. Combination Therapy of Intense Pulsed Light Therapy and Meibomian Gland Expression (IPL/MGX) Can Improve Dry Eye Symptoms and Meibomian Gland Function in Patients With Refractory Dry Eye: A Retrospective Analysis. Cornea 2016; 35:318.