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Assessment of Signs of Anterior Blepharitis Using Standardized Color Photographs

Bunya, Vatinee Y. MD; Brainard, David H. PhD; Daniel, Ebenezer MBBS, MS, MPH, PhD; Massaro-Giordano, Mina MD; Nyberg, William FBP, FOPS; Windsor, Elizabeth A. BA; Pearson, Denise J. COMT; Huang, Jiayan MS; Maguire, Maureen G. PhD; Stone, Richard A. MD

doi: 10.1097/ICO.0b013e3182a02e0e
Clinical Science

Purpose: To describe a standardized technique for acquiring and viewing photographic images of eyelids, assess the reproducibility and validity of a grading protocol for signs of anterior blepharitis, and to explore whether the signs depend on the eyelid or the area of the eyelid assessed.

Methods: Subjects with anterior blepharitis ranging from none to severe were examined by ophthalmologists at clinical sites. Digital images of the eyelids of subjects were acquired using a protocol that allowed for the calibration of color and luminance. Three ophthalmologists at a centralized reading center applied a novel protocol for grading features of anterior blepharitis from the digital images viewed on color-calibrated monitors. The agreement among graders was assessed using percent agreement and weighted kappa statistics (K w), and the correlation of photographic and clinical gradings was assessed using Spearman correlation coefficients.

Results: Agreement among graders was excellent (K w > 0.80) on the number of eyelid margin vessels and was substantial (K w between 0.61 and 0.80) for erythema, collarettes, number of engorged vessels, and number of lashes. Grading of the photographic images and the clinical assessments of erythema and lid debris were moderately correlated (r = 0.27–0.45). The grades for different features depended on whether the upper or lower eyelid, eyelid skin or lid margin, and central or lateral lid were assessed.

Conclusions: The application of a protocol to obtain and display calibrated digital images of eyelids supports the standardized assessment of anterior blepharitis in clinical care and research studies.

Supplemental Digital Content is Available in the Text.

*Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and

Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA.

Reprints: Vatinee Y. Bunya, Scheie Eye Institute, 51 N. 39th St, Myrin Circle, Philadelphia, PA 19104 (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Supported by Inspire Pharmaceuticals, Inc., grants from the National Eye Institute K12 EY015398 (VYB) and P30 EY01583(VYB, DHB, ED, MMG, WN, EW, DJP, JH, MGM, RAS), the Paul and Evanina Bell Mackall Foundation Trust (RAS), and an unrestricted grant from Research to Prevent Blindness (VYB, MMG, RAS).

The Eyelid Photography Protocol is copyright-protected by the University of Pennsylvania. Use of the protocol in investigational studies sponsored in whole or part by for-profit entities or for commercial purposes by any entities is prohibited without the express written consent of the University of Pennsylvania.

The authors retain intellectual rights to the photography protocol for the possibility of future licensing.

The authors have no other conflicts of interest to disclose.

Received June 03, 2013

Accepted June 11, 2013

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.