Blepharitis
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Direct answer
Burning, grittiness and crusted lids that feel worst on waking, recurring for years in an adult, define blepharitis — chronic inflammation of the lid margin. Anterior blepharitis involves the lash side of the margin: staphylococcal disease with hard crusted collarettes around lash bases, sometimes with lash loss and ulceration, and seborrhoeic disease with greasy scales riding on a hyperaemic margin. Posterior blepharitis is Meibomian gland dysfunction, with plugged gland orifices, telangiectatic vessels, foam in the tear lake and a poor tear film — the form most responsible for chronic irritation and for feeding chalazia. Management is a regimen, not a prescription: warm compresses, lid hygiene and massage, topical antibiotic ointment, with oral doxycycline (or azithromycin where doxycycline is contraindicated) for posterior disease and ocular rosacea.
What you must remember
- Anterior staphylococcal blepharitis: hard crusting and collarettes at lash bases, chronic conjunctivitis, sometimes marginal keratitis; complications include trichiasis, madarosis, and styes and chalazia. Seborrhoeic blepharitis adds greasy, yellowish scales on an unulcerated margin with scalp and brow dermatitis.
- Posterior blepharitis (Meibomian gland dysfunction): pouting, plugged orifices, thickened secretions, foam in the tear meniscus, telangiectasia of the posterior margin, and evaporative dry eye.
- Symptoms characteristically worse in the morning (overnight accumulation of debris and inflammation), distinguishing them from aqueous-deficient dry eye, which worsens through the day's screen use.
- Marginal catarrhal keratitis — infiltrates or small ulcers 2 to 3 mm inside the limbus — is a staphylococcal toxin-mediated complication treated with a short course of combined steroid-antibiotic drops.
- The treatment triad: warm compresses to melt secretions, lid margin scrubbing, and gland expression or massage; consistency matters more than any drug.
- Oral doxycycline 100 mg daily (low-dose, for its anti-collagenase and anti-inflammatory action) for posterior blepharitis and ocular rosacea — avoid in children under eight and in pregnancy, where azithromycin or erythromycin substitutes.
- Associated conditions to look for: rosacea (rhinophyma, facial flushing), seborrhoeic dermatitis, and dry eye; chalazion and hordeolum recurrence is the commonest presenting complication.
- Blepharitis is chronic and relapsing — the consultation sets expectations for long-term lid hygiene rather than a cure.
Working through a chronic lid margin
A 45-year-old shopkeeper describes five years of bilateral burning and grittiness, worst in the mornings, with recurring "styes" and crusted lashes he picks off each day. Slit-lamp examination reads the lid margin like a document. Along the lash line sit hard collarettes clinging to lash bases with two lashes turning in — anterior staphylococcal disease. Posteriorly, the Meibomian orifices are pouting and plugged, the margin vessels are telangiectatic, and foam floats in the tear lake; express a gland and a turbid, toothpaste-like secretion emerges — posterior blepharitis with Meibomian dysfunction. Fluorescein shows a fragmented tear film with rapid break-up, and 3 mm inside the inferior limbus sits a quiet grey infiltrate — marginal keratitis, the complication that explains his worst weeks. Build the regimen in order: warm compresses twice daily for five minutes to melt the secretions, lid scrubbing with diluted baby shampoo or a commercial lid wipe along the margin, and massage to express the glands; add erythromycin ointment to the lash bases at night for the anterior component, and a short combined steroid-antibiotic course for the marginal infiltrate while it is active. Because his posterior disease is severe and his cheeks flush easily, start low-dose doxycycline for six to eight weeks and counsel that this is a regimen for months, not a prescription for a week — the single most common reason treatment "fails" is that it stops.
Where candidates slip
Candidates prescribe antibiotic drops and stop — drops alone barely touch a disease of the lid margin and glands, and the marks sit with compresses, scrubs and expression. The second slip is the doxycycline detail: the dose is low and the purpose anti-inflammatory, not antimicrobial, and it is contraindicated in children and pregnancy. The third is misreading the morning-worse history as simple dry eye; the foam, the plugged orifices and the recurrent chalazia identify evaporative dysfunction from blepharitis, which changes both counselling and therapy.
Frequently asked questions
How are anterior and posterior blepharitis distinguished?
Anterior disease affects the lash margin — staphylococcal crusting and collarettes or greasy seborrhoeic scales; posterior disease involves Meibomian glands, with plugged orifices, telangiectasia and foam in the tears.
What is marginal catarrhal keratitis?
Sterile infiltrates or shallow ulcers 2 to 3 mm inside the limbus from staphylococcal toxin hypersensitivity in anterior blepharitis, treated with short steroid-antibiotic drops.
Why is oral doxycycline used in posterior blepharitis?
For its anti-inflammatory and anti-collagenase effects on Meibomian dysfunction at low dose, typically 100 mg daily for weeks; alternatives are azithromycin or erythromycin when doxycycline is contraindicated.
Which lid-hygiene steps form first-line treatment?
Warm compresses to melt gland secretions, followed by lid margin scrubbing and massage or expression, performed twice daily long term.
What complications follow untreated blepharitis?
Recurrent styes and chalazia, trichiasis and madarosis, chronic conjunctivitis, marginal keratitis, and evaporative dry eye.
Why do blepharitis symptoms worsen in the morning?
Because secretions, debris and inflammatory mediators accumulate overnight with the lids closed, whereas aqueous-deficient dry eye typically worsens with evening screen use.