The Preferred Practice Pattern^® (PPP) guidelines have been written on the basis of three principles.

• Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
• Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
• Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

In the process of revising this document, a detailed literature search of articles in the English language was conducted in December 2007 in PubMed and in the Cochrane Library on the subject of blepharitis for the years 2002 to 2007. The results were reviewed by the Cornea/External Disease Panel and used to prepare the recommendations, which they rated in two ways.

The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

• Level A, defined as most important
• Level B, defined as moderately important
• Level C, defined as relevant but not critical

The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The "ratings of strength of evidence" also are divided into three levels.

• Level I includes evidence obtained from at least one properly conducted, well-designed, randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
• Level II includes evidence obtained from the following:
  • Well-designed controlled trials without randomization
  • Well-designed cohort or case-control analytic studies, preferably from more than one center
  • Multiple-time series with or without the intervention
• Level III includes evidence obtained from one of the following:
  • Descriptive studies
  • Case reports
  • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review)

The evidence cited is that which supports the value of the recommendation as something that should be performed to improve the quality of care. The panel believes that it is important to make available the strength of the evidence underlying the recommendation. In this way, readers can appreciate the degree of importance the committee attached to each recommendation and they can understand what type of evidence supports the recommendation.

The ratings of importance and the ratings of strength of evidence are given in bracketed superscripts after each recommendation. For instance, "[A:II]" indicates a recommendation with high importance to clinical care [A], supported by sufficiently rigorous published evidence, though not by a randomized controlled trial [II].

The sections entitled Orientation and Background do not include recommendations; rather they are designed to educate and provide summary background information and rationale for the recommendations that are presented in the Care Process section. A summary of the major recommendations for care is included in Appendix 2.

ENTITY
Blepharitis, which may include entities with the following ICD-9 classifications:

• Blepharitis, unspecified (373.00)
• Ulcerative (373.01)
• Angular (373.01)
• Squamous (373.02)
• Stye (373.11)
• Meibomitis (373.12)
• Abscess of eyelid (373.13)
• Parasitic infestation of eyelid (373.60)

DISEASE DEFINITION
This Preferred Practice Pattern focuses on chronic blepharitis, which is a chronic ocular inflammation that involves the eyelid margin primarily and is a common cause of chronic ocular irritation.

ACTIVITY 
Diagnosis and management of the patient with blepharitis.

PATIENT POPULATION
Individuals of all ages who present with symptoms and signs suggestive of bacterial keratitis such as pain, redness, blurred vision, discharge, corneal infiltrates, ulcerations, and anterior chamber inflammation.

PURPOSE
The patient population includes individuals of all ages who present with symptoms and signs suggestive of blepharitis, such as eyelid and ocular irritation and redness.

GOALS

• Establish the diagnosis of blepharitis, differentiating it from other causes of irritation and redness 
• Identify the type of blepharitis 
• Utilize appropriate diagnostic tests 
• Establish appropriate therapy
• Relieve discomfort and pain
• Prevent complications
• Educate and engage the patient in the management of this potentially chronic disease

Blepharitis can be classified according to anatomic location: anterior blepharitis affects the base of the eyelashes and the eyelash follicles, and posterior blepharitis affects the meibomian glands and gland orifices. Blepharitis has traditionally been clinically subcategorized as staphylococcal, seborrheic, meibomian gland dysfunction (MGD), or a combination thereof.¹ Staphylococcal and seborrheic blepharitis involve mainly the anterior eyelid and can each be referred to as anterior blepharitis. Meibomian gland dysfunction involves the posterior eyelid margin. This Preferred Practice Pattern covers these three subcategories of chronic blepharitis.²

There is considerable overlap of symptoms of all types of blepharitis. Blepharitis frequently leads to associated ocular surface inflammation, including conjunctivitis, functional tear deficiency, and keratitis. Blepharitis may also exacerbate symptoms of coexisting ocular surface disease, including allergy and aqueous tear deficiency (keratoconjunctivitis sicca, or KCS). The chronic nature of blepharitis, the uncertain etiology, and the frequent coexistence of ocular surface disease make blepharitis difficult to manage.

Staphylococcal blepharitis is characterized by scaling, crusting, and erythema of the eyelid margin with collarette formation at the base of the cilia. Chronic inflammation may be punctuated by acute exacerbations that lead to the development of ulcerative blepharitis. Loss of eyelashes and corneal involvement, including punctate epithelial erosions, neovascularization, and marginal infiltrates, may occur.

Although Staphylococcus epidermidis is isolated with great frequency (in 89% to 100% of cases) from eyelids of both normal subjects and patients with blepharitis, Staphylococcus aureus is isolated with greater frequency from eyelids of patients with clinical diagnoses of staphylococcal blepharitis.¹ Both S. epidermidis and S. aureus are believed to play a role in the development of staphylococcal blepharitis, but the mechanisms of disease production remain poorly understood. Toxin production has been reported to correlate with the presence of blepharoconjunctivitis³; however, other investigators have found no correlation between toxin production of S. aureus isolates and the presence of clinical disease.⁴ Immunologic mechanisms have been documented. Blepharitis can be induced in rabbits by sensitization to S. aureus cell-wall components.⁵ Enhanced cell-mediated immunity to S. aureus has been detected in 40% of patients with chronic blepharitis but not among normal subjects.⁶ Cell-mediated immunologic mechanisms have also been implicated in the development of keratitis associated with staphylococcal blepharitis.⁷ Staphylococcal antigens themselves can initiate an inflammatory reaction by attaching to bacterial antigen-binding receptors that are present on the corneal epithelium.^8,9

Patients with seborrheic blepharitis have greasy scaling of the anterior eyelid, and they frequently have seborrheic dermatitis of the eyebrows and scalp as well.

Eyelid manifestations of MGD include prominent blood vessels crossing the mucocutaneous junction, frothy discharge along the eyelid margin, pouting or plugging of meibomian orifices, expression of meibomian secretions that range from turbid fluid to thick cheese-like material, thickening and scalloping of the eyelid margin, and chalazion. These changes can lead to eventual atrophy of meibomian glands. Patients with MGD frequently are noted to have coexisting rosacea or seborrheic dermatitis.^1,10 Alterations in the biochemical composition of meibomian gland secretions have been documented in patients with MGD blepharitis when compared with normal subjects.¹¹

EPIDEMIOLOGY
Although blepharitis is one of the most common ocular disorders, epidemiological information on its incidence or prevalence within defined populations is lacking. One single-center study of 90 patients with chronic blepharitis noted that the mean age of patients was 50 years. Compared with patients with other forms of blepharitis, patients with staphylococcal blepharitis were found to be relatively younger (42 years old) and most were female (80%).¹

ASSOCIATED CONDITIONS AND CAUSES OF BLEPHARITIS
Keratoconjunctivitis sicca has been reported to be present in 50% of patients with staphylococcal blepharitis.¹ Conversely, in a series of 66 patients with KCS, 75% had staphylococcal conjunctivitis or blepharitis.¹² It is possible that a decrease in local lysozyme and immunoglobulin levels associated with tear deficiency may alter resistance to bacteria, predisposing to the development of staphylococcal blepharitis.⁷

Twenty-five to 40% of patients with seborrheic blepharitis and MGD,¹ and 37% to 52% of patients with ocular rosacea¹⁰ have aqueous tear deficiency. This may result from increased tear-film evaporation due to a deficiency in the lipid component of the tears as well as reduced ocular-surface sensation.^13,14 Low levels of tear-film phospholipids have been found to correlate with the presence of KCS in patients with chronic blepharitis.¹⁵ Rosacea (see definition below) is associated with epithelial basement-membrane abnormalities and recurrent corneal epithelial erosions.^{16, 17}

Fluorescein tear breakup time is significantly shorter in patients with MGD, even if aqueous tear production is normal.¹⁸ This suggests that meibomian gland secretions are important in maintaining a stable preocular tear film. The overlap of clinical features of the various forms of chronic blepharitis and the variable association of all forms with tear dysfunction¹ underscore the complexity of the relationship between blepharitis and tear dysfunction as well as the need for customized treatment approaches for patients with complaints of ocular irritation.

Dermatologic conditions associated with seborrheic blepharitis and MGD may share common etiologies and predisposing factors. In one study, 95% of patients with seborrheic blepharitis also had seborrheic dermatitis.¹ In patients with a subset of MGD called primary (diffuse) meibomitis, 74% had a seborrheic dermatitis and 51% had rosacea (acne rosacea).¹

Demodex folliculorum has been found in 30% of patients with chronic blepharitis, but it has also been found with nearly the same prevalence in patients without blepharitis.¹⁹ However, patients with recalcitrant blepharitis have responded to therapy directed at eradication of the Demodex mites.¹⁹

Rosacea is a disease of the skin and eye that is observed more frequently in fair-skinned individuals,²⁰ but it can occur in people of all races. Characteristic facial skin findings include erythema, telangiectasia, papules, pustules, prominent sebaceous glands, and rhinophyma. Rosacea may be difficult to diagnose in patients with darker skin tones because of the difficulty in visualizing telangiectasia or facial flushing. Rosacea is typically seen in middle age and occurs more often in women.²¹ While rosacea is more prevalent in women, it can be more severe when it occurs in men.^22,23 Because many patients exhibit only mild signs, such as telangiectasia and a history of easy facial flushing, the diagnosis of rosacea is often overlooked, especially in children who may present with chronic recurrent keratoconjunctivitis, punctate erosions, keratitis, meibomian gland disease, or recurrent chalazia and have subtle signs of rosacea.²⁴ Children with ocular rosacea often present with corneal involvement, asymmetry of ocular disease, and the potential for sight-threatening visual impairment. Cutaneous rosacea is less frequent in children and associated atopy is common.^25,26 Children with a history of styes have an increased risk of developing adult rosacea.²⁷

Isotretinoin, an oral medication that is used to treat severe cystic acne, is associated with a significant increase in colonization of the conjunctiva with S. aureus, blepharitis, and a disruption in tear function.²⁸ Discontinuation of the medication leads to improvement in most cases.^28-31

Patients with contact-lens-associated giant papillary conjunctivitis have an increased frequency of MGD.³² The severity of giant papillary conjunctivitis may correlate with the severity of MGD.³²

Table 1 lists other entities that produce inflammation of the eyelid margin.

Table 1. Other Conditions Associated with Eyelid Inflammation.

NATURAL HISTORY
Blepharitis is a chronic condition that has periods of exacerbation and remission. Although onset usually occurs in middle-aged adults, it can begin in childhood.^24,33 Staphylococcal blepharitis may become less problematic with time. Severe staphylococcal blepharitis may eventually lead to eyelash loss, eyelid scarring with trichiasis, and corneal scarring and neovascularization.⁶ Patients with seborrheic blepharitis and MGD blepharitis are generally older and have a longer history of ocular symptoms (range 6.5 to 11.6 years).⁷ Eyelid margin telangiectasia and meibomian gland orifice narrowing and pouting may occur in asymptomatic older patients.³⁴ Patients with severe ocular rosacea may develop superficial punctate keratopathy, corneal neovascularization, and scarring.²⁰ Ulceration and perforation can occur rarely.

Early detection and appropriate treatment can reduce signs and symptoms of blepharitis and prevent permanent structural damage and possible vision loss. This is particularly important in children, in whom chronic blepharokeratoconjunctivitis is often unrecognized. It should be suspected in a child with recurrent conjunctivitis, keratitis, neovascularization, eyelid inflammation, hordeolae, and chalazia.^24-26,33,35  

Discoid lupus erythematosus can masquerade as blepharoconjunctivitis, and ulcerative blepharitis can be an early presentation of Crohn disease.^36,37 Recognizing the association of eyelid inflammation with these systemic diseases can lead to prompt and effective treatment. In cases where carcinoma masquerades as blepharitis, early diagnosis and appropriate treatment can prevent disfigurement and may be lifesaving.

PATIENT OUTCOME CRITERIA
Outcome criteria for managing blepharitis include the following:

• Reducing the symptoms and signs of blepharitis
• Minimizing structural damage
• Preventing loss of visual function

DIAGNOSIS
The initial evaluation of a patient with symptoms and signs suggestive of blepharitis should include the relevant aspects of the comprehensive medical eye evaluation.^{38,39 [A:III]} The diagnosis of blepharitis is usually based on a typical patient history and characteristic findings. Ancillary testing may be helpful.

Patient History
Questions about the following elements of the patient history may elicit helpful information:

• Symptoms and signs:^[A:III] e.g., redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, contact lens intolerance, photophobia, increased frequency of blinking
• Time of day when symptoms are worse^[A:III]
• Duration of symptoms^[A:III]
• Unilateral or bilateral presentation^[A:III]
• Exacerbating conditions:^[A:III] e.g., smoke, allergens, wind, contact lenses, low humidity, retinoids, diet and alcohol consumption, eye makeup
• Symptoms and signs related to systemic diseases:^[A:III] e.g., rosacea, allergy
• Current and previous systemic and topical medications:^[A:III] e.g., antihistamines or drugs with anticholinergic effects, or drugs used in the past that might have an effect on the ocular surface (e.g., isotretinoin)
• Recent exposure to an infected individual:^[C:III] e.g., pediculosis palpebrarum (Pthirus pubis)

The ocular history may include details about previous intraocular and eyelid surgery, as well as local trauma, including mechanical, thermal, chemical, and radiation injury. A history of cosmetic blepharoplasty is important to obtain because it can make evaporative dry eye worse. A history of styes and/or chalazia is common.

The medical history may also include information about dermatological diseases such as rosacea, atopic disease, and herpes zoster ophthalmicus.

Examination
Examination of the eye and adnexa includes measurement of visual acuity,^[A:III] an external examination,^[A:III] slit-lamp biomicroscopy,^[A:III] and measurement of intraocular pressure.^[A:III] The external examination should be performed in a well-lighted room with particular attention to the following:

• Skin^[A:III]
  • Changes consistent with rosacea such as rhinophyma, erythema, telangiectasia, papules, pustules, and hypertrophic sebaceous glands in malar areas
  • Dermatitis
  • Rash
• Eyelids^[A:III]
  • Abnormal eyelid position (i.e., ectropion and entropion)
  • Loss, breakage, or misdirection of eyelashes
  • Vascularization or hyperemia of eyelid margins
  • Abnormal deposits at base of eyelashes
  • Ulceration
  • Vesicles
  • Scaling, hyperkeratosis
  • Chalazion/hordeolum
  • Scarring

The slit-lamp biomicroscopy should include evaluation of the following:

• Tear film^[A:III]
  • Tear meniscus
  • Quality of mucus and lipid
  • Foamy discharge
  • Debris in the tear film
• Anterior eyelid margin^[A:III] Hyperemia
• Telangiectasia
• Scarring
• Pigmentary changes
• Keratinization
• Ulceration
• Vesicles
• Blood-tinged debris
• Pediculosis palpebrarum (Pthirus pubis)
• Presence of mass

Diagnostic Tests
There are no specific clinical diagnostic tests for blepharitis. However, cultures of the eyelid margins may be indicated for patients with recurrent anterior blepharitis with severe inflammation as well as for patients who are not responding to therapy. Microscopic evaluation of epilated eyelashes may reveal Demodex mites, which have been implicated in cases of chronic blepharoconjunctivitis. Demodex infestation is associated with cylindrical dandruff on the eyelashes and has been described in patients with MGD, conjunctival inflammation, and ocular rosacea. It has also been described in patients with corneal signs such as marginal infiltrate, phlyctenule, superficial vascularization, superficial opacities, and nodular scarring.^41,42

A biopsy of the eyelid may be indicated to exclude the possibility of carcinoma in cases of marked asymmetry, resistance to therapy, or unifocal recurrent chalazia that do not respond well to therapy.^{43 [A:II]} Additional signs of concern may include loss of normal eyelid margin and conjunctival anatomy, and focal madarosis. Before obtaining a biopsy for suspected sebaceous gland carcinoma, consultation with a pathologist is recommended^[A:III] to discuss the potential need for frozen sections and mapping of the conjunctiva to search for pagetoid spread. Fresh tissue may be needed to detect lipids using special dyes such as oil red-O.

Clinical features that may aid in the differential diagnosis of staphylococcal, seborrheic, and MGD blepharitis are summarized in Table 2. Clinical features of these forms of blepharitis often overlap, and patients with associated conditions such as dry eye syndrome can present with similar clinical features.

Table 2. Description of Clinical Features of Blepharitis by Category.

TREATMENT 
There is insufficient evidence to make definitive recommendations for the treatment of blepharitis,⁴⁴ and the patient must understand that a cure is not possible in most cases. Treatments that are helpful include the following:

• Warm compresses
• Eyelid hygiene
• Antibiotics (topical and/or systemic)
• Topical anti-inflammatory agents (e.g., corticosteroids, cyclosporine)

These treatment options are often used in combination. Eyelid hygiene is especially useful for anterior blepharitis, while warm compresses are especially helpful for posterior blepharitis. The optimal treatment regimen often requires a trial and error approach. An initial step in treating patients with blepharitis is to recommend warm compresses and eyelid hygiene,^{45 [A:III]} which may be accomplished in several ways.

One regimen is to apply warm compresses to the eyelids for several minutes to soften adherent encrustations and/or warm the meibomian secretions. Sustained warmth can be achieved by using hot tap water on a clean wash cloth or by heating a gel pack or bag of rice in the microwave. It is very important to instruct patients to avoid using compresses that are so hot that they burn the skin.

Eyelid hygiene can be accomplished by brief, gentle massage of the eyelids. Rubbing the eyelid margins from side to side removes crusting from the eyelashes. Cleaning the eyelid can be safely accomplished by having the patient gently rub the base of the eyelashes using either diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, or clean finger tip. Vertical eyelid massage can be used to express meibomian secretions. A schedule of regularly performed eyelid hygiene, daily or several times weekly, often blunts the symptoms of chronic blepharitis. The massage may be omitted for patients with poor manual dexterity.

Once-daily compresses and massage, at the time most convenient for the patient, is generally adequate. Frequent manipulation of the eyelid may lead to mechanically induced irritation. Some patients find it useful to repeat the warm compress and eyelid hygiene treatment during the day. Patients should be advised that warm compress and eyelid hygiene treatment, if effective, may be required long term, because the symptoms often recur if treatment is discontinued.^[A:III]

A topical antibiotic ointment such as bacitracin or erythromycin can be prescribed and applied on the eyelid margins one or more times daily or at bedtime for 1 or more weeks. In severe cases or for patients who do not tolerate ointments, metronidazole gel applied to the eyelid skin is an alternate treatment (off label).⁴⁶ The frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment.^[A:III]

For patients with MGD, whose chronic symptoms and signs are not adequately controlled with eyelid hygiene, an oral tetracycline can be prescribed.^[A:III] Doxycycline or minocycline 100 mg or tetracycline 1000 mg in divided doses can be given daily, to be tapered to doxycycline or minocycline 40 mg to 50 mg or tetracycline 250 mg to 500 mg daily after clinical improvement is noted (usually 2 to 4 weeks). Alternatively, oral erythromycin (250 mg to 500 mg daily) or azithromycin (250 mg to 500 mg, one to three times a week) can be used. Macrolide antibiotics (e.g., erythromycin, azithromycin) also have anti-inflammatory activity.⁴⁷ Treatments can be intermittently discontinued and reinstated, based on the severity of the patient's blepharitis and tolerance for the medication, and to allow recolonization of normal flora. The rationale for the use of tetracyclines is based in part on small clinical trials that report efficacy of the drugs in improving symptoms in patients with ocular rosacea⁴⁸ and improving tear breakup time in patients with rosacea and MGD.⁴⁹ The tetracyclines decrease lipase production in both S. epidermidis and S. aureus.^50,51 Tetracycline and related drugs can cause photosensitization, gastrointestinal upset, vaginitis, and, rarely, azotemia. They have been implicated in cases of pseudotumor cerebri,^52,53 and their mechanism of degradation may alter the effectiveness of certain medications (e.g., decrease the effectiveness of oral contraceptives and potentiate the effect of warfarin). A sustained-release 40-mg preparation of doxycycline can be used to reduce side effects. Tetracyclines are contraindicated in pregnancy, for nursing women, and for patients with a history of hypersensitivity to tetracyclines. Tetracyclines also should not be used in children under 10 years of age,⁵⁴ since staining of teeth may occur; however, oral erythromycin may be substituted.⁵⁵ Minocycline has been reported to stain skin, thyroid, nails, sclera, teeth, conjunctiva, tongue, and bone.^56-58

A brief course of topical corticosteroids may be helpful for eyelid or ocular surface inflammation such as severe conjunctival injection, marginal keratitis, or phlyctenules. Corticosteroid eye drops or ointments are typically applied several times daily to the eyelids or ocular surface. Once the inflammation is controlled, the corticosteroid can be tapered and discontinued and then used intermittently to maintain patient comfort. The minimal effective dose of corticosteroid should be utilized, and long-term corticosteroid therapy should be avoided if possible.^[A:III] Patients should be informed of the potential adverse effects of corticosteroid use, including the risk for developing increased intraocular pressure and cataract.^[A:III] These adverse effects may be minimized by using a site-specific corticosteroid such as loteprednol etabonate and corticosteroids with limited ocular penetration, such as fluorometholone. Guidelines for maintenance therapy should be discussed.^[A:III] Topical cyclosporine 0.05% may be helpful in some patients with posterior blepharitis.⁵⁹

Because many blepharitis patients have aqueous tear deficiency, artificial tears may improve symptoms when used as an adjunct to eyelid hygiene and medications. If used more than four times per day, nonpreserved tears should be used to avoid preservative toxicity. Topical cyclosporine and/or punctal plugs may also be helpful in managing coexisting dry eye syndrome.

Patients with atypical eyelid-margin inflammation or disease not responsive to medical therapy should be carefully re-evaluated.^[A:III] The presence of features such as nodular mass, ulceration, extensive scarring, lash loss, localized crusting and scaling of the dermis, or yellow conjunctival nodules surrounded by intense inflammation may suggest the presence of an eyelid tumor. Basal cell carcinoma and squamous cell carcinoma are the most frequently encountered malignant tumors involving the eyelids. Melanoma and sebaceous gland carcinoma are the next most frequently diagnosed malignant tumors of the eyelid.⁶⁰ Sebaceous gland carcinoma may have a multicentric origin and may induce severe conjunctival inflammation due to pagetoid spread, and it may be difficult to diagnose. Sebaceous gland carcinoma should be considered in elderly patients with unresponsive unilateral blepharitis, conjunctivitis, or recurrent chalazia.

Some patients who did not improve with the above treatments for blepharitis and rosacea improved when therapy was directed to eradicate mites. Improvement in symptoms and signs were recently reported with weekly 50% tea-tree oil eyelid scrubs and daily tea-tree oil shampoo scrubs when used for a minimum of 6 weeks.⁴² In a single case report, prolonged treatment with metronidazole gel 2% with eyelid scrubs was used to treat chronic Demodex blepharitis.⁶¹ The 2% formulation of metronidazole gel is not commercially available in the United States.

FOLLOW-UP
Patients with mild blepharitis should be advised to return to their ophthalmologist if their condition worsens.^[A:III] Visit intervals for patients are dictated by the severity of symptoms and signs, the current therapy, and comorbid factors such as glaucoma in patients who have been treated with corticosteroids. The follow-up visit should consist of an interval history, measurement of visual acuity, external examination, and slit-lamp biomicroscopy.^[A:III] If corticosteroid therapy is prescribed, patients should be re-evaluated within a few weeks to determine the response to therapy, measure intraocular pressure, and assess treatment compliance.^[A:III]

PROVIDER
The diagnosis and management of blepharitis requires broad medical skills and experience because of the potential association of systemic conditions, including cancer, with eyelid inflammation. At times, a multidisciplinary approach with a dermatologist, allergist, or oculoplastics specialist can be helpful. Patients with blepharitis who are evaluated by nonophthalmologist health care providers should be promptly referred to an ophthalmologist if any of the following occurs:^[A:III]

• Visual loss
• Moderate or severe pain
• Severe or chronic redness
• Corneal involvement
• Recurrent episodes
• Lack of response to therapy

COUNSELING/REFERRAL
One of the most important aspects of caring for patients with blepharitis is educating them about the chronicity and recurrence of the disease process.^[A:III] Patients should be informed that symptoms can frequently be improved but are rarely eliminated.^[A:III]

APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA

Providing quality care
is the physician's foremost ethical obligation, and is
the basis of public trust in physicians.
AMA Board of Trustees, 1986

Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.

The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest feasible level, consistent with the needs of patients, through training and continuing education. The ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or through referral to appropriate persons and facilities that will provide such care, and he or she supports activities that promote health and prevent disease and disability.

The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The ophthalmologist respects the dignity and integrity of his or her patients, and does not exploit their vulnerability.

Quality ophthalmic care has the following optimal attributes, among others.

• The essence of quality care is a meaningful partnership relationship between patient and physician. The ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure their meaningful participation (appropriate to their unique physical, intellectual and emotional state) in decisions affecting their management and care, to improve their motivation and compliance with the agreed plan of treatment, and to help alleviate their fears and concerns.
• The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the urgency and nature of the patient's condition and unique needs and desires.
• The ophthalmologist carries out only those procedures for which he or she is adequately trained, experienced and competent, or, when necessary, is assisted by someone who is, depending on the urgency of the problem and availability and accessibility of alternative providers.
• Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be described as follows.
  • The ophthalmologist treats patients with due regard to timeliness, appropriateness and his or her own ability to provide such care.
  • The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative patient care.
  • When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and procedures for obtaining it.
  • The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications of the person to whom the referral is made, and access and availability.
  • The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other medical or surgical problem. Consultants are suggested for their skill, competence and accessibility. They receive as complete and accurate an accounting of the problem as necessary to provide efficient and effective advice or intervention, and in turn respond in an adequate and timely manner.
  • The ophthalmologist maintains complete and accurate medical records.
  • On appropriate request, the ophthalmologist provides and full and accurate rendering of the patient's records in his or her possession.
  • The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective manner and takes appropriate actions.
  • The ophthalmologist and those who assist in providing care identify themselves and their profession.
  • For patients whose conditions fail to respond to treatment and for whom further treatment is unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and social services, and referral as appropriate and accessible.
• Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately conversant with the patient's condition by collecting pertinent historical information and performing relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks, benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks and benefits of no treatment.
• The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its demonstrated safety and efficacy.
• The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and assessing his or her personal performance in relation to established standards, and by revising or altering his or her practices and techniques appropriately.
• The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate professional channels, knowledge gained through clinical research and practice. This includes alerting colleagues of instances of unusual or unexpected rates of complications and problems related to new drugs, devices or procedures.
• The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with potential ocular and systemic complications requiring immediate attention.
• The ophthalmologist also provides ophthalmic care in a manner that is cost effective without unacceptably compromising accepted standards of quality.

Reviewed by: Council
Approved by: Board of Trustees
October 12, 1988

2^nd Printing: January 1991
3^rd Printing: August 2001
4^th Printing: July 2005

APPENDIX 2. SUMMARY OF MAJOR RECOMMENDATIONS FOR CARE

DIAGNOSIS
The initial evaluation of a patient with signs and symptoms suggestive of blepharitis should include the relevant aspects of the comprehensive medical eye evaluation.^{1,2 [A:III]}

• Symptoms and signs:^[A:III] e.g., redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, contact lens intolerance, photophobia, increased frequency of blinking
• Time of day when symptoms are worse^[A:III]
• Duration of symptoms^[A:III]
• Unilateral or bilateral presentation^[A:III]
• Exacerbating conditions:^[A:III] e.g., smoke, allergens, wind, contact lenses, low humidity, retinoids, diet and alcohol consumption, eye makeup
• Symptoms and signs related to systemic diseases:^[A:III] e.g., rosacea, allergy
• Current and previous systemic and topical medications:^[A:III] e.g., antihistamines or drugs with anticholinergic effects, or drugs used in the past that might have an effect on the ocular surface (e.g., isotretinoin)
• Recent exposure to an infected individual:^[C:III] e.g., pediculosis palpebrarum (Pthirus pubis)

The ocular history may include details about previous intraocular and eyelid surgery, as well as local trauma, including mechanical, thermal, chemical, and radiation injury. A history of cosmetic blepharoplasty is important to obtain because it can make evaporative dry eye worse. A history of styes and/or chalazia is common.

The medical history may also include information about dermatological diseases such as rosacea, atopic disease, and herpes zoster ophthalmicus.

Examination
Examination of the eye and adnexa includes measurement of visual acuity,^[A:III] an external examination,^[A:III] slit-lamp biomicroscopy,^[A:III] and measurement of intraocular pressure.^[A:III] The external examination should be performed in a well-lighted room with particular attention to the following:

• Skin^[A:III]
• Eyelids^[A:III]

The slit-lamp biomicroscopy should include evaluation of the following:

• Tear film^[A:III]
• Anterior eyelid margin^[A:III]
• Eyelashes^[A:III]
• Posterior eyelid margin^[A:III]
• Tarsal conjunctiva (everting eyelids)^[A:III]
• Bulbar conjunctiva^[A:III]
• Cornea^[A:III]

Diagnostic Tests
A biopsy of the eyelid may be indicated to exclude the possibility of carcinoma in cases of marked asymmetry, resistance to therapy, or unifocal recurrent chalazia that do not respond well to therapy.^{3 [A:II]} Before obtaining a biopsy for suspected sebaceous gland carcinoma, consultation with a pathologist is recommended^[A:III] to discuss the potential need for frozen sections and mapping of the conjunctiva to search for pagetoid spread.

Treatment
There is insufficient evidence to make definitive recommendations for the treatment of blepharitis,⁴ and the patient must understand that a cure is not possible in most cases. Treatments that are helpful include the following:

• Warm compresses
• Eyelid hygiene
• Antibiotics (topical and/or systemic)
• Topical anti-inflammatory agents (e.g., corticosteroids, cyclosporine)

An initial step in treating patients with blepharitis is to recommend warm compresses and eyelid hygiene.^{5 [A:III]} Patients should be advised that warm compress and eyelid hygiene treatment, if effective, may be required long term, because the symptoms often recur if treatment is discontinued.^[A:III]

The frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment.^[A:III]

For patients with MGD, whose chronic symptoms and signs are not adequately controlled with eyelid hygiene, an oral tetracycline can be prescribed.^[A:III] Alternatively, oral erythromycin (250 mg to 500 mg daily) or azithromycin (250 mg to 500 mg, one to three times a week) can be used.

A brief course of topical corticosteroids may be helpful for eyelid or ocular surface inflammation such as severe conjunctival injection, marginal keratitis, or phlyctenules. The minimal effective dose of corticosteroid should be utilized, and long-term corticosteroid therapy should be avoided if possible.^[A:III] Patients should be informed of the potential adverse effects of corticosteroid use, including the risk for developing increased intraocular pressure and cataract.^[A:III]

Patients with atypical eyelid-margin inflammation or disease not responsive to medical therapy should be carefully re-evaluated.^[A:III]

FOLLOW-UP
Patients with mild blepharitis should be advised to return to their ophthalmologist if their condition worsens.^[A:III] Visit intervals for patients are dictated by the severity of symptoms and signs, the current therapy, and comorbid factors such as glaucoma in patients who have been treated with corticosteroids. The follow-up visit should consist of an interval history, measurement of visual acuity, external examination, and slit-lamp biomicroscopy.^[A:III] If corticosteroid therapy is prescribed, patients should be re-evaluated within a few weeks to determine the response to therapy, measure intraocular pressure, and assess treatment compliance.^[A:III]

PROVIDER
Patients with blepharitis who are evaluated by nonophthalmologist health care providers should be promptly referred to an ophthalmologist if any of the following occurs:^[A:III]

• Visual loss
• Moderate or severe pain
• Severe or chronic redness
• Corneal involvement
• Recurrent episodes
• Lack of response to therapy

COUNSELING/REFERRAL
One of the most important aspects of caring for patients with blepharitis is educating them about the chronicity and recurrence of the disease process.^[A:III] Patients should be informed that symptoms can frequently be improved but are rarely eliminated.^[A:III]

REFERENCES

1. American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern^® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2005. Available at: http://www.aao.org/ppp.
2. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Pediatric Eye Evaluations. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.
3. Gilberg S, Tse D. Malignant eyelid tumors. Ophthalmol Clin North Am 1992;5:261-85.
4. Miller KV, Odufuwa TOB, Liew G, Anderson KL. Interventions for blepharitis (Protocol). Cochrane Database of Syst Revs 2005 Issue 4. Art. No.: CD005556. DOI: 10.1002/14651858.CD005556.
5. Key JE. A comparative study of eyelid cleaning regimens in chronic blepharitis. CLAO J 1996;22:209-12.

Basic and Clinical Science Course
External Disease and Cornea (Section 8, 2008-2009)

Eye Fact Sheets
Blepharitis (Spanish - Blefaritis) (2004)
Eyelid Margin Disease Including Blepharitis (2004)

LEO Clinical Update Course DVD-ROM
Cornea & External Disease (2007)

Preferred Practice Pattern
Comprehensive Adult Medical Eye Evaluation (2005)

To order any of these materials, please call the Academy's Customer Service number, 866.561.8558 (US only) or 415.561.8540 or visit http://www.aao.org/store.

• Level A: Most important to the care process
• Level B: Moderately important to the care process
• Level C: Relevant but not critical to the care process

Strength of Evidence Ratings:

• Level I: Randomized controlled trial or meta-analyses
• Level II: Controlled trials, cohort, or case-control studies
• Level III: Descriptive studies or case reports

1. McCulley JP, Dougherty JM, Deneau DG. Classification of chronic blepharitis. Ophthalmology 1982;89:1173-80.
2. American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. External Disease and Cornea: Section 8, 2008-2009. San Francisco, CA: American Academy of Ophthalmology; 2008:163-4.
3. Valenton MJ, Okumoto M. Toxin-producing strains of Staphylococcus epidermidis (albus). Isolates from patients with staphylococcic blepharoconjunctivitis. Arch Ophthalmol 1973;89:186-9.
4. Seal D, Ficker L, Ramakrishnan M, Wright P. Role of staphylococcal toxin production in blepharitis. Ophthalmology 1990;97:1684-8.
5. Mondino BJ, Caster AI, Dethlefs B. A rabbit model of staphylococcal blepharitis. Arch Ophthalmol 1987;105:409-12.
6. Ficker L, Ramakrishnan M, Seal D, Wright P. Role of cell-mediated immunity to staphylococci in blepharitis. Am J Ophthalmol 1991;111:473-9.
7. Bowman RW, Dougherty JM, McCulley JP. Chronic blepharitis and dry eyes. Int Ophthalmol Clin 1987;27:27-35.
8. Aderem A, Ulevitch RJ. Toll-like receptors in the induction of the innate immune response. Nature 2000;406:782-7.
9. Song PI, Abraham TA, Park Y, et al. The expression of functional LPS receptor proteins CD14 and toll-like receptor 4 in human corneal cells. Invest Ophthalmol Vis Sci 2001;42:2867-77.
10. Lemp MA, Mahmood MA, Weiler HH. Association of rosacea and keratoconjunctivitis sicca. Arch Ophthalmol 1984;102:556-7.
11. McCulley JP, Shine WE. Meibomian secretions in chronic blepharitis. Adv Exp Med Biol 1998;438:319-26.
12. Baum J. Clinical manifestations of dry eye states. Trans Ophthalmol Soc U K 1985;104 ( Pt 4):415-23.
13. Stern ME, Beuerman RW, Fox RI, et al. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea 1998;17:584-9.
14. Mathers WD. Ocular evaporation in meibomian gland dysfunction and dry eye. Ophthalmology 1993;100:347-51.
15. Shine WE, McCulley JP. Keratoconjunctivitis sicca associated with meibomian secretion polar lipid abnormality. Arch Ophthalmol 1998;116:849-52.
16. Jenkins MS, Brown SI, Lempert SL, Weinberg RJ. Ocular rosacea. Am J Ophthalmol 1979;88:618-22.
17. Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology 1997;104:1863-7.
18. Pflugfelder SC, Tseng SC, Sanabria O, et al. Evaluation of subjective assessments and objective diagnostic tests for diagnosing tear-film disorders known to cause ocular irritation. Cornea 1998;17:38-56.
19. Kemal M, Sumer Z, Toker MI, et al. The prevalence of Demodex folliculorum in blepharitis patients and the normal population. Ophthalmic Epidemiol 2005;12:287-90.
20. Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol 1986;31:145-58.
21. American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. External Disease and Cornea: Section 8, 2008-2009. San Francisco, CA: American Academy of Ophthalmology; 2008:85.
22. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol 1989;69:419-23.
23. Chalmers DA. Rosacea: recognition and management for the primary care provider. Nurse Pract 1997;22:18, 23-8, 30.
24. Viswalingam M, Rauz S, Morlet N, Dart JK. Blepharokeratoconjunctivitis in children: diagnosis and treatment. Br J Ophthalmol 2005;89:400-3.
25. Cetinkaya A, Akova YA. Pediatric ocular acne rosacea: long-term treatment with systemic antibiotics. Am J Ophthalmol 2006;142:816-21.
26. Donaldson KE, Karp CL, Dunbar MT. Evaluation and treatment of children with ocular rosacea. Cornea 2007;26:42-6.
27. Bamford JT, Gessert CE, Renier CM, et al. Childhood stye and adult rosacea. J Am Acad Dermatol 2006;55:951-5.
28. Bozkurt B, Irkec MT, Atakan N, et al. Lacrimal function and ocular complications in patients treated with systemic isotretinoin. Eur J Ophthalmol 2002;12:173-6.
29. Mathers WD, Shields WJ, Sachdev MS, et al. Meibomian gland morphology and tear osmolarity: changes with Accutane therapy. Cornea 1991;10:286-90.
30. Fraunfelder FT, Fraunfelder FW, Edwards R. Ocular side effects possibly associated with isotretinoin usage. Am J Ophthalmol 2001;132:299-305.
31. Egger SF, Huber-Spitzy V, Bohler K, et al. Ocular side effects associated with 13-cis-retinoic acid therapy for acne vulgaris: clinical features, alterations of tearfilm and conjunctival flora. Acta Ophthalmol Scand 1995;73:355-7.
32. Martin NF, Rubinfeld RS, Malley JD, Manzitti V. Giant papillary conjunctivitis and meibomian gland dysfunction blepharitis. CLAO J 1992;18:165-9.
33. Hammersmith KM, Cohen EJ, Blake TD, et al. Blepharokeratoconjunctivitis in children. Arch Ophthalmol 2005;123:1667-70.
34. Hykin PG, Bron AJ. Age-related morphological changes in lid margin and meibomian gland anatomy. Cornea 1992;11:334-42.
35. Jones SM, Weinstein JM, Cumberland P, et al. Visual outcome and corneal changes in children with chronic blepharokeratoconjunctivitis. Ophthalmology 2007;114:2271-80.
36. Acharya N, Pineda R, 2nd, Uy HS, Foster CS. Discoid lupus erythematosus masquerading as chronic blepharoconjunctivitis. Ophthalmology 2005;112:e19-23.
37. Diaz-Valle D, Benitez del Castillo JM, Fernandez Acenero MJ, et al. Bilateral lid margin ulcers as the initial manifestation of Crohn disease. Am J Ophthalmol 2004;138:292-4.
38. American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern^® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco, CA: American Academy of Ophthalmology; 2005. Available at: http://www.aao.org/ppp.
39. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Pediatric Eye Evaluations. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.
40. Bron AJ, Benjamin L, Snibson GR. Meibomian gland disease. Classification and grading of lid changes. Eye 1991;5 ( Pt 4):395-411.
41. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. Invest Ophthalmol Vis Sci 2005;46:3089-94.
42. Kheirkhah A, Casas V, Li W, et al. Corneal manifestations of ocular Demodex infestation. Am J Ophthalmol 2007;143:743-749.
43. Gilberg S, Tse D. Malignant eyelid tumors. Ophthalmol Clin North Am 1992;5:261-85.
44. Miller KV, Odufuwa TOB, Liew G, Anderson KL. Interventions for blepharitis (Protocol). Cochrane Database of Syst Revs 2005 Issue 4. Art. No.: CD005556. DOI: 10.1002/14651858.CD005556.
45. Key JE. A comparative study of eyelid cleaning regimens in chronic blepharitis. CLAO J 1996;22:209-12.
46. Barnhorst DA, Jr., Foster JA, Chern KC, Meisler DM. The efficacy of topical metronidazole in the treatment of ocular rosacea. Ophthalmology 1996;103:1880-3.
47. Ianaro A, Ialenti A, Maffia P, et al. Anti-inflammatory activity of macrolide antibiotics. J Pharmacol Exp Ther 2000;292:156-63.
48. Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani P. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol 1993;116:88-92.
49. Zengin N, Tol H, Gunduz K, et al. Meibomian gland dysfunction and tear film abnormalities in rosacea. Cornea 1995;14:144-6.
50. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The role of tetracycline in chronic blepharitis. Inhibition of lipase production in staphylococci. Invest Ophthalmol Vis Sci 1991;32:2970-5.
51. Shine WE, McCulley JP, Pandya AG. Minocycline effect on meibomian gland lipids in meibomianitis patients. Exp Eye Res 2003;76:417-20.
52. Quinn AG, Singer SB, Buncic JR. Pediatric tetracycline-induced pseudotumor cerebri. J AAPOS 1999;3:53-7.
53. Chiu AM, Chuenkongkaew WL, Cornblath WT, et al. Minocycline treatment and pseudotumor cerebri syndrome. Am J Ophthalmol 1998;126:116-21.
54. American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. Update on General Medicine: Section 1, 2008-2009. San Francisco, CA: American Academy of Ophthalmology; 2008:72.
55. Meisler DM, Raizman MB, Traboulsi EI. Oral erythromycin treatment for childhood blepharokeratitis. J AAPOS 2000;4:379-80.
56. Fraunfelder FT, Randall JA. Minocycline-induced scleral pigmentation. Ophthalmology 1997;104:936-8.
57. Bradfield YS, Robertson DM, Salomao DR, et al. Minocycline-induced ocular pigmentation. Arch Ophthalmol 2003;121:144-5.
58. Sanchez AR, Rogers RS, 3rd, Sheridan PJ. Tetracycline and other tetracycline-derivative staining of the teeth and oral cavity. Int J Dermatol 2004;43:709-15.
59. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea 2006;25:171-5.
60. Margo CE, Mulla ZD. Malignant tumors of the eyelid: a population-based study of non-basal cell and non-squamous cell malignant neoplasms. Arch Ophthalmol 1998;116:195-8.
61. Junk AK, Lukacs A, Kampik A. [Topical administration of metronidazole gel as an effective therapy alternative in chronic Demodex blepharitis--a case report]. Klin Monatsbl Augenheilkd 1998;213:48-50.

Cornea/External Disease Panel Members
Christopher J. Rapuano, MD, Chair
Robert S. Feder, MD
Matthew R. Jones, MD
Francis S. Mah, MD
Ayman Naseri, MD
Timothy W. Olsen, MD
Audrey R. Talley-Rostov, MD
Andrew J. Velazquez, MD
Jayne S. Weiss, MD
David C. Musch, PhD, MPH, Methodologist

Preferred Practice Patterns Committee Members
Sid Mandelbaum, MD, Chair
Emily Y. Chew, MD
Linda M. Christmann, MD
Douglas E. Gaasterland, MD
Samuel Masket, MD
Stephen D. McLeod, MD
Christopher J. Rapuano, MD
Donald S. Fong, MD, MPH, Methodologist

Academy Staff
Flora C. Lum, MD
Nancy Collins, RN, MPH
Doris Mizuiri
Medical Editor: Susan Garratt
Design: Socorro Soberano
Reviewed by: Council
Approved by:  Board of Trustees
September 27, 2008

These panel and committee members have disclosed the following financial relationships occurring from January 2007 to October 2008:

Robert S. Feder, MD: Alcon Laboratories, Inc. - Lecture fees
Donald S. Fong, MD, MPH: Merck - Consultant/Advisor
Douglas E. Gaasterland, MD: Inspire Pharmaceuticals - Consultant/Advisor; IRIDEX - Consultant/Advisor, Equity owner, Patents/Royalty
Francis S. Mah, MD: Alcon Laboratories, Inc. - Consultant/Advisor, Lecture fees, Grant support; Allergan, Inc. - Consultant/Advisor, Lecture fees, Grant support; BD Medical - Ophthalmic Systems - Lecture fees; InSite Vision, Inc. - Consultant/Advisor, Lecture fees, Grant support; Inspire Pharmaceuticals, Inc. - Consultant/Advisor, Lecture fees, Grant support; Ista Pharmaceuticals - Consultant/Advisor, Lecture fees, Grant support; Mpex, Inc. - Consultant/Advisor, Grant support; Polymedix, Inc. - Consultant/Advisor, Grant support; Xoma, Inc. - Consultant/Advisor, Grant support
Samuel Masket, MD: Alcon Laboratories, Inc. - Consultant/Advisor, Lecture fees, Grant support; Allergan, Inc. - Lecture fees; Bausch & Lomb, Inc. - Lecture fees; Omeros Pharmaceuticals, Inc. - Consultant/Advisor; Othera Pharmaceuticals, Inc. - Consultant/Advisor; PowerVision - Consultant/Advisor; Visiogen, Inc. - Consultant/Advisor
Stephen D. McLeod, MD: Alcon Laboratories, Inc. - Consultant/Advisor, Grant support; InSite Vision, Inc. - Consultant/Advisor, Visiogen, Inc. - Consultant/Advisor, Equity owner, Grant support
David C. Musch, PhD, MPH: Acuity Pharmaceuticals - Consultant/Advisor; AqueSys, Inc. - Consultant/Advisor; Bausch & Lomb, Inc. - Consultant/Advisor; Glaukos Corp. - Consultant/Advisor; IRIDEX - Consultant/Advisor; MacuSight, Inc. - Consultant/Advisor; Midwest EyeBanks - Grant support; National Eye Institute - Grant support; NeoVista, Inc. - Consultant/Advisor; Neurotech USA, Inc. - Consultant/Advisor; OPKO Health, Inc. - Consultant/Advisor; XTL Biopharmaceuticals - Consultant/Advisor
Ayman Naseri, MD: QLT Phototherapeutics, Inc. - Equity owner; SurModics, Inc. - Equity owner
Christopher J. Rapuano, MD: Alcon Laboratories, Inc. - Lecture fees; Allergan, Inc. - Consultant/Advisor, Lecture fees; Inspire Pharmaceuticals - Lecture fees; Ista Pharmaceuticals - Lecture fees; Rapid Pathogen Screening - Equity/owner; Ziemer Ophthalmic Systems AG - Consultant/Advisor
Audrey R. Talley-Rostov, MD: Addition Technology - Consultant/Advisor, Lecture fees; Advanced Medical Optics - Consultant/Advisor, Lecture fees; Allergan, Inc. - Consultant/Advisor, Lecture fees; Visiogen, Inc. - Consultant/Advisor
Jayne S. Weiss, MD: Alcon Laboratories, Inc. - Lecture fees

Copyright American Academy of Ophthalmology 2008
All rights reserved

AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners.

This document should be cited as:
American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern^® Guidelines. Blepharitis. San Francisco, CA: American Academy of Ophthalmology; 2008. Available at: http://www.aao.org/ppp.

As a service to its members and the public, the American Academy of Ophthalmology has developed a series of guidelines called Preferred Practice Patterns that identify characteristics and components of quality eye care. (See Appendix 1.)

The Preferred Practice Pattern^® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.

Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

The Preferred Practice Pattern^® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.  

Innovation in medicine is essential to assure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration.

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all guidelines are current, each is valid for 5 years from the "approved by" date unless superseded by a revision. Preferred Practice Patterns are funded by the Academy without commercial support.