Blefaritis

Antecedentes

Blepharitis refers to the group of conditions characterised by inflammation of the eyelid margin.¹ La blefaritis puede ser aguda o crónica y puede ocurrir a cualquier edad, pero la variante más comúnmente encontrada es la enfermedad crónica en adultos.² Esto se describirá aquí. Siga los enlaces proporcionados a lo largo de este artículo para obtener información sobre causas más agudas (por ejemplo, celulitis preseptal, infecciones por el virus del herpes simple (VHS) o el virus del herpes zóster (VHZ), etc.).³

It can be anatomically divided into anterior disease (anterior blepharitis) - which primarily affects the lashes, and posterior disease (posterior blepharitis) - which involves the meibomian glands (and so is sometimes referred to as meibomian gland disease or dysfunction). Anterior blepharitis is broadly divided into staphylococcal blepharitis and seborrhoeic blepharitis. This reflects the underlying pathophysiology to a certain degree, although there is often overlap in a given individual. It is not unusual for the different entities to be difficult to distinguish clinically in primary care.³

Patogénesis

• Anterior blepharitis is usually caused by staphylococcus (staphylococcal blepharitis) or a seborrhoeic disorder (seborrhoeic blepharitis).

  • Staphylococcal blepharitis is associated with bacteria on the ocular surface. The pathophysiology is complex and not fully understood. It may may involve direct bacterial infection, exotoxin hypersensitivity, or delayed cell-mediated immune hypersensitivity response. Other bacteria may be involved, for example, streptococci, pseudomonas.

• ²

  • Seborrhoeic blepharitis is closely associated with seborrhoeic dermatitis. Oily secretions increase and the skin becomes scaly and greasy.³

• Posterior blepharitis usually results from meibomian gland dysfunction. This is a chronic, diffuse abnormality of the meibomian glands characterised by terminal duct obstruction and/or changes in glandular secretion.²

• Blepharitis is associated with several other risk factors:

  • Dry eye disease.

  • Dermatitis seborreica.

  • Rosácea.

  • Psoriasis.

  • Éczema.

  • Demodex mites may also be a causative factor for both anterior and posterior blepharitis. The mites infest the eyelid margin around the lash follicles and sebaceous glands. It is thought that the mites or their waste or the body's inflammatory response may block follicles and gland.^{2 4}

  • Medications. Drugs that cause dry eyes (for example, anticholinergics, antihistamines) and Isotretinoin.

• Anterior blepharitis can predispose an individual to posterior disease and vice versa.⁵

• Most individuals presenting with blepharitis are thought to have a combination of causal factors. However, one factor may predominate to give a picture of a particular type of blepharitis.⁶

Epidemiología³

• Blepharitis accounts for at least 5% of ophthalmological presentations in primary care.

• The true prevalence is unknown and studies trying to estimate this have been unsatisfactory.²

• All forms are equally common in both sexes, other than staphylococcal blepharitis, which is more common in women.

• Blepharitis is a condition which most commonly starts in the fourth and fifth decades of life.

Presentación³

Síntomas

• Eyes are sore or gritty. There may be itching or burning.

• Eyelids may stick together on waking.

• Symptoms are worse in the morning.

• Symptoms are bilateral.

• There may be long periods of exacerbations and remissions.

• Puede haber síntomas asociados dry eye syndrome: watery eyes, blurred vision, dry eyes and intolerance of contact lenses.

• Puede haber síntomas asociados dermatitis seborreica: dandruff, oily skin, facial rashes.

• Puede haber síntomas asociados rosácea: facial flushing, redness or telangiectasia.

Be suspicious of unilateral disease, as lid tumours may present this way.⁷

Signos

There may be little to find on examination, in particular when compared to the severity of symptoms reported.⁷ Los márgenes de los párpados pueden estar enrojecidos, y puede haber costras o escamas visibles. Hay una serie de posibles signos, algunos característicos de cada tipo de blefaritis y muchos superpuestos donde hay patología mixta.

Diagnóstico diferencial

• Tumores del borde del párpado: carcinoma de células basales (CCB), carcinoma de células escamosas (CEC) o carcinoma de glándula sebácea.

• Dermatitis de contacto o dermatitis atópica.

• Psoriasis.

• Infección: infección por herpes simple, impétigo o celulitis.

• Conjuntivitis.

• Problemas con lentes de contacto.

• Síndrome del ojo seco.

Diagnóstico⁸

This is confirmed by clinical examination:

• Lid skin - esto puede estar ligeramente inflamado. Busque condiciones dermatológicas concurrentes: escamosas o descamativas (especialmente en enfermedades anteriores), vesículas (asociadas con infección herpética), telangiectasia o pústulas (como en pacientes con rosácea). Es particularmente importante buscar lesiones asociadas que puedan levantar sospechas de CBC o CEC.

• Lashes - la pérdida (madarosis) ocurre frecuentemente en enfermedades anteriores y ocasionalmente sucede en enfermedades posteriores de larga duración. Be wary of localised lash loss: sebaceous gland carcinoma may mimic chronic blepharitis with localised inflammation and lash loss - refer if unsure. Look for crusting (collarettes) or hard scales (staphylococcal disease) and for greasiness (seborrhoeic disease). Trichiasis (in-turning of lashes) and poliosis (whitening of lashes) may occur in long-standing disease.

• Lid margin - busque inflamación alrededor de los orificios de las glándulas de Meibomio o el taponamiento de los orificios de las glándulas de Meibomio (parece una fila de gotas amarillas a lo largo del borde del párpado) de la seborrea meibomiana.

• Película lagrimal - esto es frecuentemente deficiente en la mayoría de las formas de la enfermedad y también puede ser espumoso en la seborrea meibomiana.

• Conjuntiva - puede estar inyectado. Puede estar presente la conjuntivitis asociada. Evertir el párpado para ver la conjuntiva tarsal. Puede haber signos tempranos chalazion formación. Las cicatrices pueden ocurrir en enfermedades de larga duración.

• Córnea - las erosiones epiteliales punteadas inferiores, cicatrización y neovascularización pueden encontrarse en formas más severas de la enfermedad. El adelgazamiento y la ulceración son raros pero amenazan la visión y requieren una derivación inmediata.

• Peripheral examination para enfermedades asociadas, como problemas dermatológicos, completa tu evaluación.

Investigaciones^{8 3}

Investigations are not routinely required. Referral for slit-lamp examination would be appropriate where there are severe or resistant symptoms, or where there are signs of other eye disease. Swabbing may be appropriate in severe or recurrent cases and biopsy is mandatory in cases where malignancy is suspected (such as associated suspicious lesions or eyelash loss, usually - but not exclusively - in the older patient).

Enfermedades asociadas⁸

Blepharitis may occur on its own or in association with any of the conditions outlined in 'Differential diagnosis' (above), particularly dry eyes (keratoconjunctivitis sicca). It may also be associated with:

• Infecciones bacterianas - por ejemplo, impétigo, erysipelas.

• Infecciones virales - por ejemplo, molluscum contagiosum, varicella-zoster virus, HSV, papillomavirus.

• Infecciones parasitarias - por ejemplo, la pubic louse, Pthirus pubis.

• Enfermedad inmunológica - por ejemplo, eritema multiforme, Infección de la piel por un virus (por ejemplo,, trastornos del tejido conectivo, enfermedad de Crohn.

• Dermatosis - por ejemplo, psoriasis, ichthyosis, erythroderma.

• Tumores benignos del párpado - por ejemplo, queratosis actínica, hemangioma, granuloma piógeno.

• Trauma - for example, chemical, thermal, surgical.

La enfermedad de las glándulas de Meibomio está particularmente asociada con chalazia (obstrucción + inflamación lipogranulomatosa dentro de la glándula) y orzuelo interno (formación de absceso agudo dentro de la glándula) y pterigion. Un estudio reciente ha demostrado que la blefaritis está asociada con enfermedades sistémicas menos evidentes, incluyendo:⁹

• Síndrome del intestino irritable.

• Ansiedad y depresión.

• Enfermedades inflamatorias (por ejemplo, gastritis y peptic ulcer enfermedad, asma, colitis ulcerosa y artropatía).

• Enfermedad cardiovascular (por ejemplo, enfermedad de la arteria carótida, hiperlipidemia, hipertensión y enfermedad coronaria del corazón).

• Problemas relacionados con las hormonas (por ejemplo, hipotiroidismo y prostatic hypertrophy).

Manejo^{7 3}

Información para pacientes

Esta condición a menudo sigue un curso prolongado y su contención dependerá en gran medida de que el paciente comprenda la naturaleza del problema y cuáles son los problemas de manejo. Una dependencia de un tratamiento con antibióticos sin la participación del paciente resultará en resultados positivos limitados, si es que hay alguno. Se debe aconsejar a los pacientes que eviten el uso de lentes de contacto, especialmente durante episodios inflamatorios agudos.

However, the patient should also be reassured that this condition is rarely sight-threatening and that it should not prevent them from doing the usual activities of daily living. It is not necessary to avoid swimming, unless there is an acute infection. Eye make-up (especially eye liner and mascara) should be avoided during an exacerbation. Explain blepharitis is a chronic condition, which requires ongoing management and that self-care measures are the core of this.

Lid hygiene

This is the mainstay of treatment and may be sufficient to control simple low-grade blepharitis. It should also be used regardless of the need for additional treatment. Lid hygiene should be carried out twice a day in the acute phase and once daily at other times. There are three main aspects to this:

Gestión de infecciones

If there is an infection despite adequate lid hygiene, you may consider antibiotics:

• Se aconsejan los antibióticos tópicos como primera línea, especialmente si los signos sugieren una infección por estafilococos. Usar durante cuatro a seis semanas. El ungüento de cloranfenicol es de primera línea, con el ácido fusídico como alternativa.

• Systemic antibiotics may be used if there is no response to topical treatment, or if there are signs of rosacea or meibomian gland dysfunction. Prescribe for 6-12 weeks. Options include doxycycline, lymecycline, tetracycline and oxytetracycline. Avoid if there is likely to be excessive exposure to the sun (risk of photosensitivity), in pregnant or breastfeeding women and in children under the age of 12 years. In individuals with chronic kidney disease, avoid if possible but, if they are essential, doxycycline is a safer option in this group (the others are excreted renally). Other risks associated with tetracycline use are benign intracranial hypertension, gastrointestinal disturbances and, in women, vulvovaginal candidiasis.

• Repeated courses of antibiotics may be necessary.

• Topical and oral azithromycin have been put forward as another potential treatment option but neither is currently routinely prescribed in the UK.^{12 13}

Managing dry eye

Este es un problema que frecuentemente enfrentan los pacientes que sufren de blefaritis. El uso regular de lágrimas artificiales (por ejemplo, qds, pero ajustar hacia arriba o hacia abajo después de un período de prueba de unos días según los síntomas) y lubricantes es apropiado. Generalmente, las lágrimas artificiales son mejores para usar durante el día y los lubricantes más espesos se administran mejor al final de la noche. Vea el separado Ojos secos artículo.

Managing inflammation

Corticosteroid drops are not recommended in primary care - due to the risks associated with them - but may be used occasionally by specialists in secondary care.

Managing underlying conditions

These should be addressed as appropriate. This may not completely clear the blepharitis; however, this may go some way towards easing the symptoms and decreasing the intensity of the treatment.

Suplementación dietética

There is some evidence to suggest omega-3 fatty acids found in fish oils may improve symptoms by improving tear quality and associated dry eye symptoms.^{8 14} Se necesitan más estudios para confirmar esto y determinar las cantidades y dosis a recomendar.

Derivación

• Associated cellulitis, suspected malignancy and corneal involvement all warrant referral.

• If there is a decrease in visual acuity or the patient complains of moderate/severe pain, there may be more than blepharitis going on and referral is then also necessary.

• Uncertain diagnosis may also benefit from referral, as may the presence of concurrent disease, depending on its nature.

Complicaciones³

Complications involving the lid

• Chalazion formation: this is a meibomian cyst which is chronic and sterile, filled with lipogranulomatous material. They may be multiple and recurrent but long-standing large ones can be removed in a simple minor operative procedure in an eye unit. They can occasionally get infected (infected chalazion or internal hordeolum). Occasionally, pressure of a chalazion can cause astigmatism.

• Stye (external hordeolum): this is a painful, purulent swelling, most prominent on the outside of the eyelid, which arises due to staphylococcal infection of the follicle of an eyelash.

• Trichiasis (inward-turning of eyelashes).

• Madarosis (loss of eyelashes).

• Poliosis (loss of pigment from eyelashes).

• Cicatrización y ulceración del párpado. Esto puede a su vez causar ectropion or entropion.

Complications involving the rest of the eye

• Contact lens intolerance is common.

• Dry eye syndrome is also common - particularly in posterior blepharitis.

• Conjunctivitis - results from infiltration of the conjunctiva with bacterial debris from the eyelid.

• Conjunctival cysts (clear fluid-filled blebs) and concretions (little yellow-white fat aggregates embedded in conjunctiva - most often seen on eversion of the inferior tarsus). These tend to be asymptomatic but very large concretions may give rise to a foreign body sensation and can be removed simply with a 25 G needle, under slit-lamp examination, with a drop of local anaesthetic in situ.

• Conjuntivitis.

• Keratitis (corneal inflammation) ± ulceration. Symptoms of a foreign body sensation, pain, a red eye and photophobia would lead you to suspect this and should prompt referral for further assessment.

Pronóstico³⁸

This is a chronic condition which rarely fully resolves. Remissions, relapses and exacerbations are the norm. However, with patient education and continued adherence to lid hygiene measures (this needs to be reiterated on subsequent visits, even if the eyes are feeling comfortable), symptomatic control can be good. It will not permanently damage eyesight if the complications affecting the eyes are treated appropriately.