Blepharitis
1. 🔑 Key concept
- Blepharitis
= chronic inflammation ของ eyelid margin
- อาการเป็น chronic, recurrent, bilateral
- สัมพันธ์กับ dry eye disease (25–40%)
2. 🧠 Classification +
Pathophysiology
2.1 Posterior blepharitis (พบบ่อยที่สุด)
- เกิดที่ meibomian gland (MGD)
- กลไก:
- duct
obstruction + hyperkeratinization
- lipid
abnormality → tear
film instability
- bacterial
overgrowth →
inflammation cycle
👉 ผล:
- evaporative
dry eye
2.2 Anterior blepharitis
- ที่ eyelash base
แบ่งเป็น:
- Staphylococcal
- crust
/ collarette
- Seborrheic
- greasy
scale (คล้าย dandruff)
3. ⚠️ Predisposing factors
- Skin
disease
- rosacea
(สำคัญมาก)
- seborrheic
dermatitis
- eczema
/ psoriasis
- Infection
- Staph
- Demodex
- Irritants
- cosmetics
- contact
lens
- smoking
- Drugs
- isotretinoin
- chemotherapy
4. 🧾 Clinical features
4.1 Symptoms
- itchy
/ burning / gritty sensation
- red
swollen eyelids
- crusting
(morning)
- tearing
(paradoxical dry eye)
- transient
blurred vision
4.2 Exam findings
Eyelid
- erythema
+ crusting
- scale
around lashes
Anterior type
- collarette
(staph)
- greasy
flakes (seborrheic)
Posterior type
- MG
plugging
- thick
yellow secretion
Demodex
- cylindrical
dandruff ("sleeves")
4.3 Complications
- dry
eye (common)
- trichiasis (ขนตาเก) / madarosis (ขนตาร่วง)
- entropion
/ ectropion
- corneal:
- erosions
- infiltrates
- ulcer
(rare ⚠️)
5. 🔍 Diagnosis
- clinical
diagnosis
- slit
lamp → helpful but not
required
👉 consider:
- Demodex
→ lash microscopy
- culture
→ refractory/severe
6. ⚖️ Differential diagnosis
(important)
|
Disease |
Key clue |
|
Conjunctivitis |
discharge + conjunctival redness |
|
Hordeolum |
acute painful nodule |
|
Chalazion |
painless firm nodule |
|
Sebaceous carcinoma |
unilateral, refractory |
👉 Unilateral chronic
blepharitis → rule
out malignancy
7. 🚨 Indications for
referral
- ↓ vision
- severe
pain / photophobia
- corneal
involvement
- refractory
case
- suspected
malignancy / Demodex
8. 🧑⚕️ Management (stepwise
practical)
8.1 First-line (ทุกคน)
👉 Lid hygiene =
cornerstone
- warm
compress 5–10 min (2–4×/day)
- lid
massage
- lid
cleaning
- artificial
tears
👉 trial ~6 weeks
8.2 Avoid triggers
- cosmetics
- allergens
- smoking
8.3 Topical antibiotics (if not improved)
- bacitracin
/ erythromycin ointment
- apply
HS x 2 weeks
- azithromycin
eye drops (posterior type)
8.4 Oral antibiotics (moderate–severe)
- doxycycline
/ tetracycline
- azithromycin
(alternative)
👉 mechanism:
- ↓ bacteria
- ↓ lipase
- ↓ inflammation
👉 useful in:
- rosacea-associated
blepharitis
8.5 Refractory cases
(ต้อง ophthalmologist)
- topical
steroid (short course ⚠️ glaucoma)
- topical
cyclosporine
- tacrolimus
(off-label)
8.6 Demodex treatment
- tea
tree oil
- ivermectin
- lotilaner
eye drop
9. ❌ Ineffective therapy
- omega-3
→ evidence mixed / not
recommended routinely
10. 💡 Clinical pearls (ใช้จริง)
- chronic
bilateral irritation = blepharitis
- posterior
type = most common + dry eye
- lid
hygiene = treatment หลัก
- antibiotic
= add when not improving
- doxycycline
= key drug (esp. rosacea)
- unilateral
refractory →
think malignancy
- Demodex
= cylindrical dandruff
11. 🧾 Practical algorithm
1.
Chronic lid irritation → suspect blepharitis
2.
Start:
o lid
hygiene + artificial tears
3.
Reassess 4–6 wk
4.
Not improved →
topical antibiotic
5.
Moderate/severe →
oral doxycycline
6.
Refractory →
refer + steroid/cyclosporine
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