KINGDOM OF SAUDI ARABIA

MINISTRY OF HIGHER EDUCATION

QASSIM UNIVERSITY
COLLEGE OF APPLIED MEDICAL SCIENCES
OPTOMETRY DEPARTMENT

Eye Infections
And Blepharitis
By: Mohsen N Alenezi

1431 AH

WWW.QUCAMS.EDU.SA
 Eye Infection

An eye infection is usually a condition caused by bacteria or a virus. While there are many
different types of eye infections with different causes and treatments, the most common
is bacterial conjunctivitis, commonly known as pink eye. Another well known infection is
blepharitis – chronic inflammation of the eyelid due to infection. One of the most well-known
forms of blepharitis is staphylococcal. Styes are another common form of eye infection. A stye is
an infection in the tiny oil glands, along the edge of the eyelid, that surround the base of an
eyelash.

The eye is constantly exposed to a variety of pathogens, but infections occur when the normal
defenses of the eye are compromised. The source of the infection may be local (e.g., from the
eyelids) or remote (e.g., from the sinuses) and can be the result of trauma, eye surgery, contact
lens wear, immune deficiencies, or other diseases resulting in bacteria growth or viruses.

Symptoms of Various Eye Infections

Bacterial conjunctivitis, or pink eye, results in red, itchy eyes that burn and discharge liquid.
There may be more tearing than usual and your eyes may appear swollen.

Blepharitis is one of the most common disorders of the eye and is often the underlying reason for
eye discomfort, redness and tearing. Other eye symptoms of blepharitis include: burning, itching,
light sensitivity, and an irritating, sandy, gritty sensation that is worse upon awakening. In
staphylococcal blepharitis, there is scaling and crusting along the eye lashes.

Styes usually begin as a red, tender bump, and usually come to a head in about three days. The
stye then breaks open and drains and heals in about a week.

Eye Infection Affect

Eye infections can occur in any age group of patients, and since relatively benign infections can
develop into serious disorders, most eye care practitioners treat infections aggressively. People
who have undergone eye surgery or experienced trauma to the eye are at higher risk of incurring
infection. And because some eye infections are highly contagious, such as pink eye, those who

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 come in contact with someone who has the infection are at a much higher risk of becoming
infected.

How to Avoid Eye Infections

Eye infections may be spread through contact with the eye drainage, which contains the virus or
bacteria that caused the infection. Touching an infected eye leaves drainage on your hand. If you
touch your other eye or an object when you have drainage on your hand, the virus or bacteria can
be spread. Here are some ways to prevent the spread of eye infections:

 Wash your hands before and after touching your eyes or face and before and after using medicine
in your eyes.
 Do not share eye makeup.
 Do not use eye makeup until the infection is fully cured, because you could reinfect yourself with
the eye makeup products. If your eye infection was caused by bacteria or a virus, throw away
your old makeup and buy new products.
 Do not share contact lens equipment, containers, or solutions.
 Do not wear contact lenses until the infection is cured. Thoroughly clean your contacts before
wearing them again and replace your contact lens case.
 Do not share eye medicine.
 Do not share towels, linens, pillows, or handkerchiefs. Use clean linens, towels, and washcloths
daily.
 Wash your hands and wear gloves if you are looking into someone else's eye for a foreign object
or helping someone else apply an eye medicine.
 Wear eye protection when in the wind, heat, or cold to prevent eye irritation.
 Wear safety glasses when working with chemicals.
 Avoid exposing your eyes to contaminated water.

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Eye Infections Treatment
Effective treatment of an eye infection first depends on an accurate diagnosis by the
physician. Conjunctivitis is highly contagious and treatment may require absence from work or
school. Often a general practitioner can prescribe an anti-infective topical solution or ointment
for treatment. It's important not to rub the eyes, because doing so contaminates hands and fingers.
Hands should be washed thoroughly and often throughout the day. Warm compresses applied to
the eye can sooth the symptoms.

The treatment for blepharitis is similar to the treatment for other eye infections. A warm compress
on the infected eye is the most critical element of effective treatment. This therapy removes the
eyelid debris, reduces the bacteria and stabilizes the tear film by releasing oily secretions from eye
glands.

Following basic guidelines for stye infections can help reduce the seriousness and the duration of
the stye. Home treatment such as not wearing eye makeup or contact lenses until the stye has
healed, and applying warm, wet compresses to the eye several times daily should heal the stye in
days. If home treatment does not work, prescription medications, such as eye ointments or eye
drops, may be needed. Talk with a health professional if a stye becomes very painful, grows larger
quickly, or continues to drain (particularly if the drainage is pus) or if the redness and swelling
around a stye spreads over the eyelid, inside the eyelid, or over the eyeball.

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 Chronic marginal blepharitis

Chronic marginal blepharitis is a very common

cause of ocular discomfort and irritation. It may be
subdivided into anterior and posterior, although
there is often considerable overlap in symptom and
features of both are often present. Patients with
anterior disease tend to be younger than those with
posterior blepharitis, but both types can result in
conjunctivitis, keraitis, exacerbation of ocular allergy
and dry eye. The poor correlation between symptoms
and signs, uncertain aetiology and mechanisms of
the disease process, conspire to make management difficult.

NB: Some signs of blepharitis (e.g. lid margin telangiectasis, pouting of

meibomian gland orifices) may occur as a part of the normal aging process in
asymptomatic individuals.

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Anterior blepharitis
Pathogenesis

Anterior blepharitis effect the area surrounding the base of the eyelashes and may be
staphylococcal or seborrhoeic.

Staph. epidermidis and P. acnes are normal skin flora, but staph. aureus is more common in
patients with staphylococcal blepharitis than in unaffected individuals. The inflammatory
capacity of components of the cell wall of Gram-positive bacteria is well documented and it is
possible that there is also an abnormal cell-mediated response to some components of the cell wall
Staph. aureus. This response may also be responsible for the red eye reaction and the peripheral
corneal infiltrates seen in some patients. Seborrhoeic blepharitis is often associated with
generalized seborrhoeic dermatitis that may involve the scalp, nasolabial folds, behind the ears,
and the sternum.

NB: Because of the intimate relationship between the lids and ocular surface,
chronic blepharitis may cause secondary inflammatory and mechanical
changes in the conjunctiva and cornea.

Diagnosis

1- Symptoms do not provide a reliable clue to the type of blepharitis.

Burning grittiness, mild photophobia, and crusting and redness of lid margins with
remissions and exacerbation are characteristic.
Symptoms are usually worse in the mornings, although in patients with associated dry eye
they may increase during the day.

NB: Because of poor correlation between the severity of symptoms and clinical
signs, it can be difficult to objectively assess the benefit of treatment.

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2- Signs
a. Staphylococcal blepharitis
 Hard scales and crusting mainly located around the bases of the lashes
(collarettes) (Figs 1.3 and 1.4).
 Mild papillary conjunctivitis (Figs. 1.5) and chronic conjunctival hyperaemia are
common (Fig. 1.6).
 Acute folliculitis and external hordeola (styes) may develop by spread of
infection to the lash follicles (Fig. 1.7).
 Lid margin ulceration in severe disease.
 Scarring and notching (tylosis) of the lid margin in long-standing cases
(Fig. 1.8).

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  The lashes in longstanding cases may become white (poliosis) (Fig. 1.9), thin and
fewer in number (madarosis) (Fig. 1.10), and misdirected inwards (trichiasis)
(Fig. 1.11).
 Secondary corneal changes include superficial punctate corneal erosion
involving the inferior third of the cornea, marginal keratitis (Fig. 1.12),
phlyctenulosis (Fig. 1.13) and vascularisation (Fig. 1.14).
 Associated tear film instability and dry eye are common.
b. Seborrhoeic blepharitis
 Hyperaemic and greasy anterior lid margins with sticking together of lashes (Fig.
1.15).
 The scales are soft and located anywhere on the lid margin and lashes (Fig. 1.16).
 The majority of patients have seborrhoeic dermatitis elsewhere (Fig. 1.17).

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 3- Investigations
a. Cultures may be taken in severe cases, but this not otherwise indicated. Staph. aureus
are the most common isolates, antibiotic sensitivity spectrum and clinical response to
antibiotic treatment.
b. Biopsy should be performed if tumor is suspected.

Treatment

There is little evidence to support any particular treatment protocol for anterior blepharitis.
Patient should be advised that lifelong treatment may be necessary, that a permanent cure is
unlikely, but that control of symptoms is usually possible. In longstanding cases, several weeks of
intensive treatment may be needed to achieve improvement.

1. Lid hygiene
 A warm compress applied for several minutes to soften crusts at the bases of the
lashes.
 Lid cleaning to mechanically remove crusts involves scrubbing the lid margins once
or twice daily with a cotton bud dipped in a dilute solution of baby shampoo or
sodium bicarbonate.
 Commercially produced soap/alcohol impregnated pads for lid scrubs are available,
but care should be taken not to induce mechanical irritation.
 The eyelids can also be cleaned with diluted shampoo when washing the hair.
 Gradually, lid hygiene can be performed less frequently as the condition is brought
under control, but blepharitis often recurs if it is stopped completely.
2. Antibiotics
a. Topical sodium fusidic acid, bacitracin or choramphenicol is used to treat acute
folliculitis but is of limited value in longstanding cases. Following lid hygiene, the
ointment should be rubbed onto the anterior lid margin with a cotton bud or clean
finger.
b. Oral azithromycin (500 mg daily for 3 days) may be helpful to control ulcerative lid
margin disease.
3. Week topical steroids such as fluorometholone 0.1% q.i.d. for one week is useful in
patients with severe papillary conjunctivitis, marginal keratitis and phlyctenulosis,
although repeated courses may be required.
4. Tear substitutes are required for association tear film instability and dry eye.
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Posterior blepharitis
Pathogenesis

Posterior blepharitis caused by meibomian gland dysfunction with keratinisation of the

meibomian gland orifices and gland dropout, although it is unclear if these are primary or
secondary phenomena. Alterations in meibomian gland secretion cause relative loss of non-polar
lipids and an increase in cholesterol esters, waxes and unsaturated fatty acids.

Bacterial lipases may give rise to formation of free fatty acids. This results in an increase in the
melting point of the meibum, preventing expression from the glands, so contributing to ocular
surface irritation and possibly enabling growth of staph. Aureus. Loss of the tear film
phospholipids that act as surfactants results in increase tear evaporation and osmolarity, and an
unstable tear film. There is a strong association between meibomian gland dysfunction and acne
rosacea (Fig. 1.18).

Diagnosis

There is a poor correlation between the severity of symptoms and the clinical signs.

1- Symptoms are similar to anterior blepharitis.

2- Signs of meibomian gland dysfunction
 Excessive and abnormal meibomian gland secretion which may manifest as capping
of meibomian gland orifices with oil globules (Fig. 1.19).
 Pouting recession, or plugging of meibomian gland orifices (Fig. 1.20).
 Pressure in the lid margin results in expression of meibomian fluid that may be
turbid or appear like toothpaste (Fig. 1.21); in sever secretions become so inspissated
that expression impossible.
 The posterior lid margin shows hyperaemia and telangiectasia (Fig. 1.22).
 Lid transillumination may show gland loss and cystic dilatation of meibomian ducts.
 Meibomian cysts are common and may be multiple and recurrent (Fig. 1.23).
 The tear film is oily and foamy, and froth may accumulate on the lid margins or
inner canthi (Fig. 1.24). the tear film break-up time may be reduced; about 40% of
patients have associated aqueous tear film deficiency.

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  Conjunctival changes include papillary conjunctivitis, inclusion cysts and
concretions (Fig. 1.25). subconjunctival scarring associated with shortening of the
fornices may occur in chronic disease.
 Inferior corneal puncture epithelial erosions are common.

Treatment

It is very important to inform the patient that cure is unlikely. Although remission may be
achieved, recurrence is common, particularly if treatment is stopped.

1- Lid hygiene
 Warm compresses and hygiene are performed as for anterior blepharitis except
the emphasis is on massaging the lid to express accumulated meibum.
 Massaging toward the lid margin edge to ‘milk’ meibum and physical expression
of the glands by the physician is of uncertain benefit (see Fig. 1.21).
2- Systemic tetracyclines are the mainstay of treatment.
 The rational for the use of tetracyclines is their ability to block staphylococcal
lipase production at concentrations well below the minimum inhibitory
concentration. They also inhibit the action of tear matrix metalloproteinase.
 Tetracyclines are particularly indicated in patients with recurrent phlyctenulosis
and marginal keraitis, although repeated courses of treatment may be needed.
 Gastrointestinal upset is the most common side effect.
 Tetracyclines inhibit absorption of oral contraceptive.

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  Photosensitization and pigmentation of the skin and mucous membranes can
occur.

NB: Tetracyclines should be not used in children under the age of 12 years
(erythromycin is an alternative) or in pregnant or breastfeeding woman,
because they are deposited in growing bone and teeth, and may cause staining
of teeth and dental hypoplasia.

a. Oxytetracyclines 250mg b.d. for 6-12 weeks; tetracycline probably has a similar
effect although evidence is lacking.
b. Doxycycline 100 mg b.d. for 1 week and then daily for 6-12 weeks.
c. Minocycline 100 mg daily for 6-12 weeks; skin pigmentation may develop after
prolonged use (Fig. 1.26).
d. Erythromycin 250 mg b.d. may be used in children.
3- Topical therapy involves antibiotic, steroids and tear substitutes for evaporated dry eye.

Associated conditions
1. Tear film instability and dry eye is found in 30-50% of patients, probably as a result of
imbalance between the aqueous and lipid components of the tear film allowing increased
evaporation. Tear film break-up time is typically reduced.
2. Chalazion formation, which may be multiple and recurrent, is common, particularly in
patients with posterior blepharitis.
3. Epithelial basement membrane disease and recurrent epithelial erosion may be
exacerbated by posterior blepharitis.
4. Cutaneous
a- Acne rosacea is often associated with meibomian gland dysfunction (se Fig. 1.18).
b- Seborrhoeic dermatitis is present in >90% of patients with seborrhoeic blepharitis (see
Fig. 1.17).

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 c- Acne vulgaris treatment with isotretinoin is associated with the development of
blepharitis in about 25% of patients; it subsides when the treatment is stopped.
5. Bacterial keraitis is associated with ocular surface disease secondary to chronic blepharitis.
6. Atopic keratoconjunctivitis is often associated with staphylococcal blepharitis. Treatment
of the blepharitis often helps the symptoms of allergic conjunctivitis and vice versa.
7. Contact lens intolerance. Long term contact lens wear associated with posterior lid margin
disease. Inhibition of lid movement and the normal expression of meibomian oil may be the
cause. There may also be associated giant papillary conjunctivitis, making comfortable lens
wear difficult. Blepharitis is also a risk factor for contact lens-associated bacterial keraitis.

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Differential diagnosis
A number of conditions may masquerade as chronic blepharitis. Misdiagnosis may delay initiation
of appropriate treatment and can be life threatening.

1. Infiltrating lid tumours should be suspected in patients with apparently asymmetric or

unilateral chronic blepharitis, particularly when associated with loss of lashes (Fig. 1.27).
2. Ocular cicatricial pemphigoid and other mucocutaneous disorders.
3. Dermatoses with lid margin involvement, most notably, discoid lupus erythematosus,
posterior and ichthyosis.
4. Factitious blepharitis, especially in patients with chronic unilateral conjunctivitis.

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Index

Eye Infection … 2

Symptoms of Various Eye Infections … 2

Eye Infection Affect … 2

How to Avoid Eye Infections … 3

Eye Infections Treatment … 3

Chronic Marginal Blepharitis … 5

Anterior Blepharitis … 6
Pathogenesis … 6
Diagnosis … 6
Treatment … 10
Posterior Blepharitis … 11
Pathogenesis … 11
Diagnosis … 11
Treatment … 13
Associated Conditions … 14
Differential Diagnosis … 16
Index … 17
References … 18

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References
1. Ocular inflammatory disease
Jack J Kanski
Carlos E Pavesio
Stephen J Tuft

2. Website :
http://www.alcon.com/en/patients-family/eye-infections.asp

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