Sufferers of blepharoconjunctivitis describe a typical blepharitic picture of eye irritation with foreign body sensation and crusting of the eyelids along with reports of red eyes. Symptoms are generally worse in the morning, and patients may report eyelids being stuck shut upon waking. Usually, both eyes are affected, and symptoms can fluctuate.

With regards to signs on examination, the patient will likely exhibit a rapid tear film break up time (<10 seconds) when visualized with fluorescein under blue light, and there may be corneal erosions or ulceration. Inspection of the sclera and conjunctivae will show varying degrees of conjunctival injection.

If the underlying blepharitis is anterior in origin, the eyelid margin will appear edematous. The eyelid margin will be erythematous, and telangiectasia may be seen. There may be crusting on the eyelid margin with the formation of collarettes at the base of the lashes. In chronic cases, there may be changes in the eyelashes themselves, such as poliosis (depigmentation), trichiasis (change in direction), or madarosis (reduction in the number of eyelashes). The eyelid may be distorted, and ectropion or entropion may be visible.

If the underlying blepharitis is posterior in origin, the Meibomian glands will be dilated, and the aperture clogged with a visible 'head' or 'cap' of thick oil. On slit-lamp examination, these 'heads' appear like a string of pearls lying on the eyelid margin. The eyelid immediately surrounding the glands may be scarred or visibly inflamed.

Blepharoconjunctivitis is a clinical diagnosis based upon the history, signs, and symptoms of the patient. Investigations such as tear film break up time can be useful but is not necessary. In cases that are refractory to treatment, one should consider lid biopsy to rule out a malignancy. Examination with fluorescein drops and blue light can be useful to detect corneal erosions or ulcers, which are associated with chronic poorly controlled blepharoconjunctivitis.

The mainstay treatment of blepharoconjunctivitis is meticulous lid hygiene. Using a warm eye compress for 5 to 10 minutes helps to soften the oil within the Meibomian glands. Massaging of the lid margin can help express the oil, and an eyelash scrub with a mild shampoo removes debris. Lid hygiene should be encouraged even after an acute exacerbation has subsided due to the chronic nature of the condition. Artificial tears can aid dry eye symptoms, and topical steroids are useful in the acute inflammatory stages of an exacerbation. Topical antibiotics should be offered if lid hygiene alone is insufficient, and this proves to be especially effective if the cause is bacterial such as in a staphylococcal infection.[19] Cases of seborrheic blepharitis often coincide with seborrheic dermatitis. These patients will benefit from concurrent treatment of the underlying dermatitis. In patients suffering from posterior blepharitis, oral azithromycin can prove useful.[20]

Supplementation of omega-3 and omega-6 fatty acids to alleviate dry eye symptoms is a controversial topic. A recent Cochrane systematic review suggested that Omega-3 supplementation may be beneficial but states the quality of evidence is poor.[21]

In patients who are refractory to treatment, it is important to rule out malignancy, especially if there are lash changes. Malignancy tends to affect the lower lid, and there should be a high index of suspicion if the symptoms are unilateral. Patients with dry eye syndrome may present with a similar 'gritty' foreign body sensation in their eyes. However, they will usually lack the inflammation and crusting on the lid margins.

Prognosis is generally good, and the majority of patients achieve symptomatic relief. Due to the chronic nature of the condition, ongoing meticulous lid hygiene is necessary as maintenance therapy to prevent acute exacerbations.

Complications can occur in long-term chronic cases. Involvement of the cornea, such as ulceration, scarring, or vascularization, is possible. Additionally, the lid margin can be distorted, leading to trichiasis, ectropion/entropion, or madarosis. Ulceration or perforation requires urgent aggressive therapy to prevent further permanent vision impairment.

Patients need to be educated that this is a chronic condition that requires ongoing maintenance therapy (lid hygiene in most cases) to prevent acute exacerbations. Patients should be educated on the symptoms of complications and advised to seek urgent medical advice if there is any deterioration in vision or new eye pain.

Health professionals such as optometrists, nurses, pharmacists, or primary care clinicians who may be the first port of call for mild ailments should be aware of the importance of lid hygiene in blepharoconjunctivitis and the practicalities surrounding this. When symptoms persist despite proper treatment, an ophthalmologist should be consulted. Excellent communication within the interprofessional team is vital to improve patient outcomes. Disseminating accurate advice is central to preventing exacerbation of blepharoconjunctivitis, particularly in the initial stages. Promoting prevention education can help to reduce the need for ophthalmic consultation and empower patients to engage with their own care.

As discussed, there is a subset of patients who may benefit from dermatology input. These individuals should be identified early and discussed with dermatologist colleagues to ensure the patient is receiving optimal care.