• Chronic blepharitis is persistent inflammation of the margins of the eyelid, which are typically red, encrusted, sore, and itchy. It is often associated with seborrhoeic dermatitis or rosacea.

• If there is rapid onset of visual loss or an acutely painful red eye, refer for same-day evaluation — see Referral criteria.
• Assess the severity of blepharitis and its impact on the person — severity of examination findings can correlate poorly with severity of symptoms.
• Assess the type of blepharitis — see Diagnosis. Ask about previous treatments and response.
• Assess for dry eyes and other complications of blepharitis — see Complications.
• Assess for associated conditions that might also need managing — see the CKS topics on:
• Seborrhoeic dermatitis.
• Rosacea.

In depth

• Blepharitis is a chronic or intermittent condition, and although it often cannot be cured, symptoms can be controlled with adequate self-care measures and complications are rare.
• Compliance with treatment, especially eyelid hygiene, is essential and should be continued even when the condition is well controlled.
• For people with internet access, www.goodhope.org.uk is a useful resource provided by the NHS.

In depth

• Advise the person that good eyelid hygiene is the mainstay of treatment and should be carried out twice daily initially, then reduced to once daily. The eyelids should be cleaned in a stepwise manner:
• Apply warm compresses to the closed eyelids for 5–10 minutes.
• For posterior blepharitis, massage the eyelid to express Meibomian glands.
• Clean the eyelid — wet a cloth or cotton bud with cleanser (e.g. baby shampoo diluted with warm water) and rub along the lid margins.
• Avoid eye make-up, especially eyeliner. If this is not possible, use an eyeliner that washes off easily.
• Blepharitis frequently causes dry eye. Prescribe artificial tears or an ocular lubricant to relieve symptoms (for more information, see the CKS topic on Dry eye syndrome).
• Consider prescribing topical antibiotics (chloramphenicol or fusidic acid) or oral antibiotics (tetracyclines) if there are clear signs of staphylococcal infection or Meibomian gland dysfunction, respectively. Antibiotics should usually be reserved for second-line use when eyelid hygiene alone has proved ineffective — see Second-line treatment.

In depth

• Ask about eyelid hygiene. If this has been complied with, but is ineffective on its own, consider offering antibiotics (if not already tried):
• Topical antibiotics should usually be tried first, especially if there are signs of staphylococcal infection on the anterior lid margins. A 6-week trial course is usually adequate. Chloramphenicol eye ointment is a suitable first-line option; fusidic acid eye drops are an alternative.
• Consider prescribing oral tetracyclines if topical antibiotics have failed to elicit an adequate response, or if there are signs of Meibomian gland dysfunction or rosacea. Low-dose tetracycline, oxytetracycline, lymecycline, or doxycycline for 6–12 weeks is recommended. Repeated courses are often required intermittently.

In depth

• Refer for same-day ophthalmological assessment if there is sudden onset of visual loss or an eye becomes acutely painful and red.
• Refer with urgency appropriate to the problem if there is:
• Persistent localized disease or resistance to treatment or marked eyelid asymmetry (to exclude cancer of the eyelid margin).
• Evidence of corneal disease (pain, blurred vision).
• Deterioration of vision.
• Uncertainty about the diagnosis.
• Associated disease, such as Sjögren's syndrome or eyelid deformities.
• Insufficient improvement despite maximal treatment available in primary care (for secondary care treatment, such as corticosteroids).

In depth