Blepharitis is a very common inflammatory disorder of the edge of the eyelids where the eyelashes are located. Bacteria, which normally exist on our skin, are drawn to crusts around the base of the eyelashes and produce chemical substances which irritate the eyes resulting in itching, irritation and burning of the eyes. The ducts of special glands, called meibomian glands, which are located in the eyelids just behind the eyelashes, become blocked. These glands are important in helping to prevent the film of tears which covers the very sensitive cornea (the clear window of the eye) from evaporating too rapidly in between blinks, as they produce the mucus layer of the tear film.

Blepharitis results in:

• Tear film instability which in turns results in irritation, a foreign body sensation, burning, itching and redness of the eyes (dry eye symptoms)

• Tearing of the eyes due to an overproduction and overflow of tears as a reflex reaction to eye irritation

• Red inflamed eyelid margins (see photograph below)

• Cyst formation in the eyelid (chalazion or meibomian cyst – see photograph below)

• Loss of eyelashes

• Inturning of the eyelid margins (entropion) resulting in painful rubbing of the eyelashes against the cornea

• Corneal ulcer (marginal ulcer or marginal keratitis)

How do I know if I have blepharitis?

The edges (rims) of the eyelids become red and the eyelashes tend to stick together with visible tiny crusts. The eyes themselves are often red and sore. In the mornings the eyelids tend to stick together, sometimes with a yellow discharge.

These changes cause the eyes to be sore and irritable, with a gritty foreign body feeling and with an aversion to lights (photophobia). Watery eyes due to the reflex production of excess tears is common.

What causes blepharitis?

Blepharitis is more common in people with certain skin conditions:

• Seborrhoeic dermatitis – a common scaly skin disorder. This typically results in dandruff and sometimes a rash on the cheeks and forehead.
• Rosacea – a skin disorder that typically affects the cheeks and nose. The associated symptoms include facial flushing, facial redness, and red spots. (Click here to read a recent review article on ocular manifestations of rosacea).
• Eczema (atopic dermatitis) – an itchy inflammatory condition of the skin which tends to flare-up from time to time. It can be associated with a variety of allergies.

There are 2 main types of blepharitis:

• Anterior blepharitis

Tiny dandruff-like flakes accumulate along the bases of the eyelashes. Bacteria invade the flakes and cause anterior blepharitis in some people (see photograph below illustrating anterior blepharitis). Seborrheoic dermatitis, which typically causes dandruff, can also cause these flakes to accumulate along the eyelid margin.

Anterior blepharitis

• Posterior blepharitis:

A row of special glands in the upper and lower eyelids (the meibomian glands) secrete an oily substance that coats the tear film and prevents the film from evaporating in between blinks. In some people the ducts of the meibomian glands become blocked. This results in a disorder referred to as meibomitis or meibomian gland disease.

Posterior blepharitis

Meibomitis in turn results in:

1. Instability of the tear film and dry eye syndrome: the oily secretions can no longer coat the tear film effectively and this results in the tear film evaporating too rapidly leaving the eye feeling irritable and sore

2. A frothy discharge on the eyelid edges

3. Clogging up of the meibomian gland ducts on the eyelid edges resulting in the formation of a plug (see photograph below)

Blocked meibomian gland orifices

4. The formation of eyelid cysts (chalazia or meibomian cysts) as the blocked meibomian gland swells and bursts its capsule resulting in a red swollen eyelid (see photograph below)

An upper lid chalazion

Is it serious?

No. Blepharitis only very rarely causes any permanent damage to the eyes. However, blepharitis is a very persistent problem. (Blepharitis which is confined to the eyelid(s) on one side only should, however, be viewed with great suspicion as very rarely tumours e.g. rodent ulcers, can mimic blepharitis and lead to misdiagnosis).

Treatment can usually only control the problem and cannot get rid of it altogether.

What is the treatment?

Strict hygiene of the eyelids is the mainstay of treatment and should be undertaken in the morning and evening for the first 2-3 weeks and then at least once every day indefinitely to keep the inflammation under control. 

There are 3 steps needed for effective lid hygiene:

1. The application of heat

2. Massage

3. Cleaning

Heat application:

Heat applied to the eyelids for 5 minutes:

• Softens the skin and any crusts that are attached to the eyelids/eyelashes
• Helps to unplug the ducts of the meibomian glands
• The traditional method is to apply a hot moist flannel or cotton pad to the closed eyelids. This is somewhat tedious because the flannel or cotton wool pad cool quickly and need to be repeatedly heated up in hot water
• The Optase heat mask is a much more convenient and effective method of heat application because it provides sustained warmth for 5-10minutes – this is available to purchase at the Face & Eye Clinic

Click here to see how to use an Optase heat mask and for more information about the management of blepharitis.

New Blephasteam is an alternative option for patients with more severe symptoms – click here for more information about Blephasteam.

Massage:

• Massage the eyelids with your forefinger straight after applying the warmth.

• Massaging helps to force out the oily fluid from the meibomian glands which then helps to stabilise the tear film on the surface of the eye.

• Massage the upper eyelid and the lower eyelid gently towards the eye. This action should be repeated 5 to 10 times over about 30 seconds immediately following the application of heat.

• Massaging should neither to be too gentle nor too firm. It should be relatively comfortable and you should not press hard enough to actually hurt your eye under the closed eyelids.

Cleaning:

After heat application and massage, clean the eyelids.

Blephaclean® wipes twice daily for 1 or 2 weeks are an excellent way to achieve rapid control of blepharitis. Click here to see how to use these wipes. (These wipes are particularly useful in removing eye make-up, avoiding irritation/allergy associated with other eye make-up removers). Blephasol® solution on a cotton bud once daily can then be used as daily maintenance to keep the eyelid margins clean.

Microblepharoexfoliation (MBE)

This new treatment is performed using an instrument called BlephEx™, a handheld device with a high-speed/high-torque rotating PVA sponge. Click here to see how this is performed. The spinning tip is first soaked and softened in a lid cleaning solution. The spinning tip is then used to mechanically debride the lid margins and remove crusts and debris.

By eliminating the inflammatory debris associated with blepharitis, the overall health of the eyelid is improved. Patients can then begin to produce better meibomian gland secretions and finally enjoy a life free from the chronic and irritating symptoms associated with blepharitis and its subsequent evaporative dry eye problems.

Click here to watch a video of Mr Ataullah performing this treatment on a patient at the Face & Eye Clinic – https://www.youtube.com/watch?v=iRM_rbpXvCk&feature=youtu.be

Visit www.blephexlids.co.uk for more information.

This treatment has recently been highlighted in the press: http://www.dailymail.co.uk/health/article-3908398/amp/A-deep-clean-procedure-chronic-eyelid-infections-offered-British-clinics.html

Antibiotic ointment:

In severe blepharitis a topical antibiotic (e.g. Chloramphenicol ointment) can be applied to the lid margins after performing lid hygiene for a period of 2 weeks. This can reduce the bacteria contributing to eyelid margin inflammation and make it easier to control blepharitis using the treatment described above.

Ointments/drops containing steroids should not be used unless prescribed by an ophthalmologist.

Oral antibiotics:

Occasionally if posterior blepharitis cannot be controlled with local treatment as described above it is worth considering a 6-12 weeks course of oral doxycycline (typically 100mg taken orally once daily) or a shorter course of Clarithromycin as this can reduce the inflammation associated with blepharitis. N.B. This cannot be used during pregnancy.

Is that all I have to do?

Since blepharitis causes tears to be abnormal, artificial tears can give relief from irritation, even when your eyes are watering (eyes can water as a reflex reaction to a basic dry eye problem or tear film abnormality). These should be used at least 4 times a day at least to prevent symptoms rather than to just relieve symptoms. There is a large variety of artificial tear preparations to choose from. It is preferable to use preservative free drops. These can be purchased from the clinic.