Acute ulcerative blepharitis is usually caused by bacterial infection (usually staphylococcal) of the eyelid margin at the origins of the eyelashes; the lash follicles and the meibomian glands are also involved. It may also be due to a virus (eg, herpes simplex, varicella zoster). Bacterial infections typically have more crusting than the viral type, which usually has more of a clear serous discharge.
Acute nonulcerative blepharitis is usually caused by an allergic reaction involving the same area (eg, atopic blepharodermatitis and seasonal allergic blepharoconjunctivitis, which cause intense itching, rubbing, and a rash; or contact sensitivity [dermatoblepharoconjunctivitis]).
In acute ulcerative blepharitis, small pustules may develop in eyelash follicles and eventually break down to form shallow marginal ulcers. Tenacious adherent crusts leave a bleeding surface when removed. During sleep, eyelids can become glued together by dried secretions. Recurrent ulcerative blepharitis can cause eyelid scars and loss or misdirection (trichiasis) of eyelashes.
In acute nonulcerative blepharitis, eyelid margins become edematous and erythematous; eyelashes may become crusted with dried serous fluid.
Acute ulcerative blepharitis is treated with an antibiotic ointment (eg, bacitracin/polymyxin B, erythromycin, or gentamicin 0.3% qid for 7 to 10 days). Acute viral ulcerative blepharitis is treated with systemic antivirals (eg, for herpes simplex, acyclovir 400 mg po tid for 7 days; for varicella zoster, famciclovir 500 mg po tid or valacyclovir 1 g po tid for 7 days).
Treatment of acute nonulcerative blepharitis begins with avoiding the offending action (eg, rubbing) or substance (eg, new eye drops). Warm compresses over the closed eyelid may relieve symptoms and speed resolution. If swelling persists > 24 h, topical corticosteroids (eg, fluorometholone ophthalmic ointment 0.1% tid for 7 days) can be used.