Blepharoconjunctivitis - Types, Symptoms, and Treatment

Introduction:

Tears are an essential component of the visual system. It helps to keep the eye moist and smooth. Not only that, but it also helps protect the eye from foreign bodies and creates a smooth surface for proper refraction.

Dry eye disease is a condition characterized by tear deficiency in the eye. The deficiency may be caused by decreased production of tears or may be caused by excessive evaporation. This condition leads to visual problems and irritation in the eye. This condition can be a single entity or may be caused by other factors like diseases. This is a very common clinical condition. Around 7.8% of people in the western world suffer from such conditions.

On the other hand, the prevalence of dry eye disease is slightly higher in the Asian population, where 14.5% of people are affected by this condition. Aqueous deficiency and evaporation are two main causative factors for dry eye disease. Evaporation causes excessive loss of water from the eye. One of the most common conditions that lead to evaporation is blepharoconjunctivitis. Proper clinical pathological evaluation is needed to identify this common condition.

What Is Blepharoconjunctivitis?

Blepharoconjunctivitis is a condition that is a combination of two diseases; these are blepharitis and conjunctivitis. Blepharitis is the inflammation of the eyelid, and conjunctivitis is the infection of the white transparent membrane of the eye. This condition starts with the inflammation of the eyelid and gradually progresses to the conjunctiva. In simple words, blepharoconjunctivitis is a mature form of blepharitis.

Several factors cause blepharoconjunctivitis. These are:

• Staphylococcal infection.

• Seborrhoeic dermatitis.

• Meibomian gland dysfunction.

• Moraxella infection.

• Allergic infection from contact dermatitis.

• Various factors cause meibomian gland dysfunction.

Dry eye disease is mainly associated with infectious and allergic blepharoconjunctivitis.

What Is the Pathophysiology?

Allergic blepharoconjunctivitis or atopic blepharoconjunctivitis is a contact dermatitis-type infection. Several allergens like acrylic, cosmetics, and dust particles cause it. Contact with these foreign particles leads to both immediate and delayed hypersensitivity reactions.

Immediate type or type I hypersensitivity is an IgE-mediated reaction that causes the degranulation of mast cells and the release of histamine. This hypersensitivity reaction occurs in two phases; one is the immediate hypersensitivity reaction caused by the release of histamine and lipid mediators. The next phase, or the late phase hypersensitivity reaction, occurs after one to three days with the release of additional mediators. Histamine and cytokine released due to this reaction cause vasodilatation and smooth muscle spasms.

A delayed type of hypersensitivity, or type IV hypersensitivity, is an IgG-mediated reaction. This cell-mediated response involves T-lymphocytes, monocytes, and macrophages. The macrophages produce IL-12 which causes stimulation and proliferation of CD4 T cells. These CD4 T lymphocytes secrete IL-2, interferon-ɣ, and cytokines. T-cells destroy the target cells, and macrophages produce hydrolytic enzymes like TNF-α. The over-reaction of T-helper cells and hydrolytic enzymes damage tissue and cause cell death.

In the case of bacterial infection, endotoxins produced by the bacteria cause inflammation. These inflammatory cytokines destabilize the tear film of the eye. Phospholipase produced by the bacteria further causes cell destruction and membrane damage.

One of the leading causes of team tear film disruption and dry eyes is meibomian gland dysfunction. Infection, inflammation due to allergens, and hormonal disruption may lead to hyperkeratinization, increased viscosity, and atrophy of the secretory acini. These changes lead to reduced secretion from the gland and loss of tear film stability.

What Are the Signs and Symptoms?

Patients often complain of the following things:

• Redness of the eye.

• Presence of the foreign body in the eye.

• Itching sensation and difficulty in eye-opening.

• Diminished vision and photophobia.

• Symptoms are worse in the morning; eyelids are stuck after waking.

Both eyes are affected due to this chronic condition. Patients often give a history of rubbing their eyes. The signs of such conditions may vary according to the cause and location of the infection.

• Loss of Eyelashes - This clinical presentation is typically present in infectious conditions. Allergic blepharoconjunctivitis rarely show such a condition, and in meibomian gland dysfunction, it is not seen.

• Eyelid Crusting - Hard, matted, fibrinous crusting is seen in infectious conditions, and in allergic conditions, crusting is oily or greasy.

• Rosacea - Blushing and flushing of the blood vessels are commonly seen in meibomian gland dysfunction and also can be seen in allergic conditions.

• Keratitis - inferior punctate epithelial erosions are seen in all conditions. Phlyctenulosis or nodular infection of the cornea is seen in infectious conditions.

According to the location, blepharoconjunctivitis can be of two types:

1. Anterior in Origin - In this condition, the following clinical features can be seen:

• Edematous eyelid margin.

• The eyelid is erythematous.

• Telangiectasia (small, widened blood vessels) is present.

• Trichiasis: Change in the direction of eyelashes.

• Poliosis: Depigmentation of eyelashes.

• Madarosis: Loss of eyelashes.

2. Posterior in Origin - The clinical signs present in this condition are:

• Dilatation of meibomian glands.

• Distortion of the eyelid.

How to Diagnose Blepharoconjunctivitis?

In most cases, a diagnosis is made based on clinical examination and the history of the condition. Diagnostic tests which can be performed in this case are:

• Tear Film Break-up Test: This is the most common procedure to determine dry eye disease. In this test, 2% fluorescein dye is given into the patient’s eye in the lower fornix region. The patient is asked not to blink, and the eye is observed under a slit lamp in cobalt blue illumination. After the first blink, the dye changes its color to green. In the dry area, a black spot appears gradually. The time between the black spot’s appearance and the first blink is calculated. Tear film break-up time is more than 10 seconds in the normal eye, 5- 10 seconds is considered marginal dry eye, and less than 5 seconds means the dry eye is present.

• Slit Lamp Test: This method examines the eye under a low-powered microscope in the presence of filtered light.

How to Treat Blepharoconjunctivitis?

The primary treatment for this condition is to ask the patient to maintain eyelid hygiene. The patient is asked to clean the eyelid with water and a clean cloth. Warm compression for 5 to 10 minutes a few times a day can be helpful. Massaging the lid margin and scrubbing with moist cloth help to clean debris.

• To alleviate dry eye conditions, artificial eye drops are given.

• Topical antibiotics such as Bacitracin, Erythromycin, Azithromycin, or Tobramycin can be prescribed.

• The topical application of steroid ointments can help reduce inflammation.

Conclusion:

Dry eye disease is a common clinical entity. Proper examination and diagnosis can help identify the pathology behind this condition. Blepharoconjunctivitis is a common and chronic infection of both the eyelid and cornea. If not treated timely, it may cause ulceration and perforation of the cornea. That is why determining the etiology in such cases can help to treat the patients.