Blepharitis / hordeolum / chalazion (F72)

March 3, 2023

Clinical course of blepharitis, hordeolum and chalazion

Blepharitis is an inflammation of the eyelid, usually localised on the inner part at the Meibomian glands (posterior blepharitis), or at the base of the eyelashes (anterior blepharitis). Meibomian glands (sebaceous glands) secrete the oily layer in the tear film. Altered gland secretions in posterior blepharitis lead to an instable tear film and toxic effects on the eye surface, leading to bacterial growth. In anterior blepharitis, Staphylococci and Demodex mite seem to play a role. Chronic skin diseases such as rosacea, seborrhoeic dermatitis, eczema and psoriasis may predispose to blepharitis. (Contact) allergens and cigarette smoking may trigger or exacerbate it. Blepharitis occurs mostly bilaterally, sometimes asymmetrical. It tends to recur.

Symptoms are red or pink and swollen eyelids with scaling of the skin and crusts around the eyelashes. Burning or itchy sensations and excessive tearing may occur. 

Eyelid hygiene is the most important aspect in the treatment of blepharitis. Irritants and allergens (e.g. cosmetics, contact lenses) should be avoided. Artificial tear eye drops are often needed for associated symptoms of dry eyes. Topical antibiotics are advised when initial treatment fails after a few weeks. Referral to an ophthalmologist is needed only in severe cases. 

Hordeolum and chalazion are unilateral nodular lesions of the eyelid. 

A hordeolum (stye) is an acute inflammation of a gland in the internal or external surface of the upper or lower eyelid often caused by bacteria (mostly Staphylococcus aureus). It presents as a tender, swollen, erythematous nodulus which may be purulent. Often spontaneous improvement occurs within two weeks but warm compresses may help to accelerate perforation resulting in pain relief. (Topical) antibiotics are usually not necessary but preseptal cellulitis is a relatively rare but serious infection requiring oral antibiotics. 

A chalazion is a sterile lipogranuloma caused by an obstructed Meibomian gland. It presents as a subcutaneous swelling in the eyelid, most commonly the upper eyelid. The swelling is painless, firm, and often small in size. Typically, spontaneous improvement occurs after several months. Warm compresses and massage can facilitate drainage of the obstructed gland. Therapeutic options for chalazia that do not improve spontaneously are intralesional corticosteroid injection or surgical removal. This can be performed by the GP with sufficient expertise or by the ophthalmologist after referral. 

How is blepharitis, hordeolum and chalazion recorded in FaMe-Net?

The ICPC-2 classification uses code F72 for all three eyelid conditions. Therefore, based on the ICPC-code it cannot be distinguished which specific eyelid condition has been diagnosed. In FaMe-Net, additional coding with ICD-10 does specify blepharitis, hordeolum or chalazion so that the distinction is possible in additional data extraction. 

Eyelid conditions should be distinguished from conjunctivitis although overlap may exist with blepharitis. Infectious conjunctivitis is coded F70. Allergic conjunctivitis is coded F71.

Epidemiology of blepharitis, hordeolum and chalazion in FaMe-Net

Blepharitis, hordeolum and chalazion have an incidence of 13.0 per 1000 patient years (13 new diagnoses per 1000 patients per year), with a higher incidence over 45 years of age. Link/Figure 1

Prevalence of blepharitis, hordeolum and chalazion is 14.1 per 1000 patient years, meaning that among 1000 patients in a year 14 seek help from their GP for these conditions. Link/Figure 2 

Incidence and prevalence numbers are quite similar, which suggests that only a few episodes of eyelid conditions require repeated GP interference and that most episodes are handled within one consultation. 

Incidence and prevalence are higher in women than in men. The sex difference is most pronounced in the oldest age group (75+) where incidence and prevalence numbers of women almost double those for men. The time trend graph suggests that the sex difference has arisen in recent years. Incidence and prevalence in men remained quite stable from 2014-2021 but in women an increase appeared since 2014-2015. We do not have an obvious explanation for this observation other than guessing. 

Blepharitis, hordeolum and chalazion (as coded together with F72) is a relatively common condition, ranked 37 in the top list of incident diagnoses. For patients aged 45-64 years the condition is ranked 24. Link/Table 3

How do patients with blepharitis, hordeolum and chalazion present to their GP?

The commonest initial reason for encounter (RFE) for blepharitis, hordeolum and chalazion is eyelid symptoms (F16), in 27% of all episodes. The second most common RFE is a self-diagnosed eyelid condition (F72) in 20%. Other important RFEs are a red eye (F02), a painful eye (F01) or abnormal appearance of the eye (F15). Link/Table 4 In older patients, eye discharge (F03) is another common RFE. Link/Table 5

How do FaMe-Net GPs act?

Apart from health education, the commonest intervention for eyelid abnormalities that were presented to the GP was a prescription, which occurred in 57% of the episodes annually. Only 1% of the cases led to incision/drainage, excision or local infiltration by the GP. Referrals occurred in 7% of the episodes. Link/Table 6 This concerned referrals to the ophthalmologist and in rare cases to the dermatologist. Link/Table 7 

Prescriptions mostly concerned topical antibiotics (e.g. chloramphenicol or fusidic acid), in 48% of the episodes. ‘Other ophtalmological’ prescriptions (S01XA) include artificial tears and were prescribed in 4%. Combination eye drops of corticosteroids and antibiotics were prescribed in 2% and anti-allergic eye drops in 1%. Link/Table 8

Reference list:
  1. van Leeuwen, M. van den Maegdenbergh, B.A.E. van de Pol, J. de Waard. Oogheelkunde (uit de reeks ‘Praktische huisartsgeneeskunde’). Bohn Stafleu van Loghum, Houten, 2016. 
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