Blepharitis and Uveitis

Question 1

What is blepharitis?

Answer 1

Blepharitis refers to the group of conditions characterised by inflammation of the eyelid margin.

Blepharitis can be acute or chronic and can occur at all ages but the most commonly encountered variant is chronic adult disease.

Question 2

What is the classification of blepharitis?

Answer 2

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.

Question 3

What is the pathogenesis of blepharitis?

Answer 3

In most cases the pathogenesis is unclear.

Blepharitis is caused by staphylococcal infection, seborrhoeic dermatitis, meibomian gland dysfunction, or any combination of these factors.

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.

Question 4

What is the presentation of blepharitis?

Answer 4

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.

There may be symptoms of associated dry eye syndrome: watery eyes, blurred vision, dry eyes and intolerance of contact lenses.

There may be symptoms of associated seborrhoeic dermatitis: dandruff, oily skin, facial rashes.

There may be symptoms of associated rosacea: facial flushing, redness or telangiectasia.

The margins of the eyelids may be reddened, and there may be visible crusting or scaling.

Question 5

What are the differentials of blepharitis?

Answer 5

Tumours of the eyelid margin: BCC, SCC or sebaceous gland carcinoma.

Contact dermatitis or atopic dermatitis.

Infection: impetigo or cellulitis

Conjunctivitis

Contact lens problems

Dry eye syndrome

Question 6

How do you diagnose blepharitis?

Answer 6

Lid skin:
-This may be slightly inflamed. Look for concurrent dermatological conditions: scaly or flaking (especially in anterior disease), vesicles (associated with herpetic infection), telangiectasia or pustules (such as in patients with rosacea).

Lashes

• Loss (madarosis) frequently occurs in anterior disease and occasionally happens in long-standing posterior disease.
• Be wary of localised lash loss: sebaceous gland carcinoma may mimic chronic blepharitis with localised inflammation and lash loss - refer if unsure.

Lid margin
-Look for inflammation around the meibomian gland orifices or the capping of the meibomian gland orifices

Tear film
-This is frequently deficient in most forms of the disease.

Conjunctiva:

• May be injected
• Associated conjunctivitis may be present.

Cornea

Peripheral examination for associated disease.

Question 7

What are the investigations for blepharitis?

Answer 7

There are no specific tests: diagnosis is made on examination.

Referral for slit lamp examination would be appropriate where there are severe or resistant symptoms, or where there are signs of other eye disease.

Question 8

What are the associated diseases of blepharitis?

Answer 8

May occur on its own or in association with any of the conditions outlined in the differentials particularly dry eyes.

It may be associated with:

• Bacterial infections such as impetigo and erysipelas.
• Viral infections such as molluscum contagiosum, varicella-zoster virus, HSV and papillomavirus.
• Immune disease such as erythema multiforme, pemphigoid, Crohn’s disease.
• Dermatoses such as psoriasis, ichthyosis and erythrodema.
• Actinic keratosis, haemangioma, pyogenic granuloma.
• IBS
• Anxiety and depression.

Question 9

What is the management of blepharitis?

Answer 9

Lid hygiene is the mainstay of treatment and should be carried out daily.

• Warm compresses which helps to loosen crusting
• Lid massage
• Lid cleansing

Managing infection - if there is an infection despite adequate lid hygiene, you may consider antibiotics:

• Topical antibiotics are advised first-line, particularly if signs suggest staphylococcal infection. Use for six weeks. Chloramphenicol ointment is first-line, with fusidic acid as an alternative.
• 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 breast-feeding women and in children under the age of 12.
• Dry eye- The regular use of artificial tears (eg, qds, but adjust up or down after a trial period of a few days according to symptoms) and lubricants is appropriate. Generally, artificial tears are best used in the day and the thicker lubricants are best administered last thing at night.
• Manage underlying condition

Question 10

What is the advise given to patients with blepharitis?

Answer 10

Patient information:

• Avoid contact lens wear
• Reassured that it is rarely sight-threatening
• They should carry on with usual activities of daily living other than wearing make up.
• Explain it is a chronic condition that can be controlled.

Question 11

What are the complications of blepharitis?

Answer 11

Madarosis (loss of eyelashes)
Poliosis (loss of pigment from eyelashes)
Stye
Chalazion formation:
Trichiasis (inward-turning of eyelashes)
Lid scarring and ulceration.
Contact lens intolerance 
Dry eye syndrome
Conjunctivitis 
Keratitis

Question 12

What is style?

Answer 12

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.

Question 13

What is chalazion formation?

Answer 13

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.

Question 14

What is the prognosis of blepharitis?

Answer 14

Chronic condition which rarely fully resolves.

Remissions, relapses and exacerbations are the norm.

Question 15

What is uveitis?

Answer 15

Uveitis is inflammation of the uveal tract, with or without inflammation of neighbouring structures (eg, the retina or vitreous).

One of the leading causes of preventable severe visual loss.

Question 16

What is the classification of uveitis?

Answer 16

-May be unilateral or bilateral
Unilateral conditions are commonly acute and can be infectious
Bilateral conditions are due to chronic, systemic conditions.

-May be anterior, intermediate, posterior or panuveitis.

-May be acute or chronic:
Acute conditions typically have an abrupt onset lasting several weeks. If left untreated, an acute condition can develop into a chronic cellular response.
Chronic uveitis is active uveitis that persists longer than three months. It is associated with a high incidence of vision-threatening complications, such as cataract, macular oedema and glaucoma, which may cause irreversible visual loss

-May be granulomatous or not

Question 17

What is anterior uveitis?

Answer 17

Anterior describes inflammation of the iris (iritis) or anterior cyclitis.

Question 18

What is intermediate uveitis?

Answer 18

Intermediate uveitis affects the vitreous and posterior part of the ciliary body. It is also referred to as pars planitis or posterior cyclitis, or as hyalitis when the inflammation involves only the anterior portion of the vitreous.

Question 19

What is posterior uveitis?

Answer 19

Posterior uveitis describes inflammation of the choroid. It is also referred to as choroiditis, or as chorioretinitis if the retina is also involved.

Question 20

What is granulomatous uveitis?

Answer 20

Keratic precipitates (KPs) are clusters of white blood cells found on the posterior (endothelial) part of the cornea, resembling little white spots.

Those which are larger and greasy looking are referred to as mutton-fat KPs.

Uveitis is classified by the morphology of the KPs into non-granulomatous (small KPs) and granulomatous (mutton-fat KPs):

Non-granulomatous uveitis is more common. It is usually anterior and has an acute onset accompanied by a cellular reaction in the anterior chamber, involving smaller cell types (lymphocytes) than those in granulomatous inflammation. It is most commonly idiopathic or due to HLA-B27 involvement.

Granulomatous uveitis is usually chronic. There are large inflammatory cells in the anterior chamber. It is often associated with systemic conditions and autoimmune reaction, or arises from the host’s immune response to a systemic infectious process, such as syphilis, Lyme disease, tuberculosis or herpetic viral infection.

Question 21

What is the aetiology of uveitis?

Answer 21

The various forms of uveitis represent the common end result of multiple underlying causes of ocular inflammation. These include:

• Inflammatory - due to autoimmune disease.
• Infectious - caused by known ocular and systemic pathogens.
• Infiltrative - secondary to invasive neoplastic processes (sometimes referred to as masquerade syndromes). Intraocular lymphoma may present as a chronic uveitis in older patients. Intraocular tumours may also occasionally present with posterior uveitis.
• Trauma - a common cause of anterior uveitis. Sympathetic ophthalmia (sometimes referred to as sympathetic ophthalmitis) is a rare form of bilateral panuveitis in response to trauma or surgery to one of the eyes.
• Iatrogenic - caused by surgery, inadvertent trauma, or medication (eg, rifabutin, cidofovir.
• Inherited - secondary to metabolic or dystrophic disease.
• Ischaemic - caused by impaired circulation.
• Idiopathic - when evaluation has failed to find an underlying cause. Most uveitis, particularly anterior uveitis, is idiopathic.
• Immunosuppression causes a particular risk of infection-related uveitis.

In Britain, sarcoidosis is the most common systemic disease that presents as chronic uveitis. In Japan, Behçet’s disease is the most common systemic disease associated with chronic uveitis and, in other parts of the world, it may be tuberculosis

Question 22

What is the pathophysiology of uveitis?

Answer 22

Uveitis is the eye’s response to a wide range of intraocular inflammatory diseases of infectious, traumatic, genetic or autoimmune aetiology.

The end pathology results from the presence of inflammatory cells and the sustained production of cytotoxic cytokines and other immune regulatory proteins in the eye.

Fuchs’ heterochromic uveitis is the most common.

Question 23

What is the presentation of acute anterior uveitis?

Answer 23

Unilateral 
Pain, redness and photophobia
Eye pain worse when reading 
Progressive 
Blurred vision 
Excess tear production 
Associated headache

Question 24

What is the presentation of chronic anterior uveitis?

Answer 24

Recurrent episodes
Blurred vision and mild redness
Little pain or photophobia

Question 25

What is the presentation of intermediate uveitis?

Answer 25

Painless floaters and decreased vision

Minimal signs of inflammation such as redness or pain

Question 26

What is the presentation of posterior uveitis?

Answer 26

Gradual visual loss 
Usually bilateral
Blurred vision and floaters 
Sudden bilateral loss of vision
The presence of symptoms of posterior uveitis WITH pain suggests:
-Anterior chamber involvement (panuveitis).
-Bacterial endophthalmitis.
-Posterior scleritis.
-Orbital inflammatory disease.

Question 27

What are the signs of uveitis?

Answer 27

KPs 
Ciliary flush 
Miosis 
Corneal oedema 
Hypopyon if significant inflammation
VA may be reduced 
Aqueous humour may be cloudy with flare- flare is graded from 0 to +4.

Question 28

What are the differentials of uveitis?

Answer 28

Any cause of a red eye

Question 29

What are the investigations for uveitis?

Answer 29

Imaging helpful if there is posterior disease.

angiography and optical coherence tomography (OCT) are the commonly used techniques.

To look for underlying cause:

• FBC
• ESR
• HLA
• Mantoux test
• CXR (sarcoidosis or TB)
• Urinalysis
• Infection work up

Question 30

What is the management of uveitis?

Answer 30

Urgent referral to ophthalmologist.

The aims of treatment are to control inflammation, prevent visual loss and minimise long-term complications of the disease and its treatment.

There is no standard regimen: treatment is determined by the type of uveitis, whether it is secondary to infection and whether it is likely to threaten sight.

Cycloplegic-mydriatic drugs (eg, cyclopentolate 1%) are used to paralyse the ciliary body. This relieves pain and prevents adhesions between the iris and lens.

IOP should be checked and herpes simplex virus keratitis ruled out before starting topical corticosteroids.

Corticosteroids are used to reduce inflammation and prevent adhesions in the eye. They may be given topically, orally, intravenously, intramuscularly, or by periocular or intraocular injection, depending on the severity of the uveitis.

Infectious uveitis is treated with an appropriate antimicrobial drug as well as corticosteroids and cycloplegics.

Severe or chronic uveitis may be treated with laser phototherapy, cryotherapy or vitrectomy.

Biologics, which target mediators of the inflammation cascade, may offer the potential to provide more effective and less toxic treatment

Question 31

What are the complications of uveitis?

Answer 31

Visual loss 
Secondary cataract 
Cystoid macular oedema 
Vitreous opacities 
Retinal detachment
Macular ischaemia