Blepharitis

By Marilyn Haddrill, with contributions and review by Brian Chou, OD

Blepharitis is a common eyelid inflammation that is sometimes associated with a bacterial eye infection, symptoms of dry eyes or certain types of skin conditions such as acne rosacea.

Blepharitis has two basic forms:

• Anterior blepharitis, affecting the outside front of the eyelid where eyelashes are attached.
• Posterior blepharitis, linked to dysfunction of meibomian glands found in the inner eyelid where oily secretions are released to help lubricate the eye.

It's common to have a mixture of both anterior and posterior forms of blepharitis at the same time, but in different degrees of severity.

Although eye doctors commonly diagnose blepharitis, it can be difficult to find permanent relief of the symptoms that can include burning, flaking, crusting, tearing, irritation, itching, redness in eyelid margins and a foreign body sensation.

Treatment for Blepharitis

If you are diagnosed with chronic blepharitis, your eye doctor will likely recommend an ongoing regimen of eyelid hygiene (see sidebar) that can include commercially developed, over-the-counter lid scrubs or other recommended cleansing agents. Eyelid hygiene is the cornerstone of treatment for most cases of blepharitis.

Besides a program of eyelid hygiene, the severity of the blepharitis and related symptoms may require supplemental treatment with topical and oral medicine.

In some cases of posterior blepharitis, eye doctors recommend nutritional supplementation with omega-3 fatty acids, such as flaxseed oil, to aid healthy function of meibomian glands that provide essential lubrication for eye and eyelid comfort.

Anterior Blepharitis

Symptoms of bacteria-caused staphylococcal blepharitis often are more severe and can even lead to loss of eyelashes.

Besides eyelid cleansing and hygiene, an antibiotic ointment for eyelids might be prescribed. Pink eye due to bacteria — a common type of eye infection — may occur simultaneously with blepharitis.

Viruses and other types of bacteria besides staphylococcus also can cause anterior blepharitis.

Without treatment, blepharitis caused by bacteria can cause long-term effects such as ectropion, thickened lid margins, dilated and visible capillaries, trichiasis and entropion. The lower third of the cornea may exhibit significant erosion from eyelids rubbing against the eye.

Seborrheic blepharitis is caused by seborrheic dermatitis, a skin condition that creates flaking and scaling — including on the eyelids. Regular cleansing with eyelid scrubs and gentle, non-detergent shampoos can provide significant relief and improve the appearance of eyelids.

The American Academy of Dermatology notes that the causes of these skin conditions are not well understood. But seborrheic dermatitis sometimes appears in a person with a weakened immune system. Fungi or certain types of yeast that feed on oils (lipids) in the skin also may lead to seborrheic dermatitis, with accompanying blepharitis.

With demodex blepharitis, microscopic mites (demodex folliculorum) and their waste materials could cause clogging of follicles at roots of eyelashes, and in some cases might be associated with development of skin conditions such as rosacea and blepharitis. A commercial eyelid scrub combined with tea tree oil may be effective for treating this type of blepharitis.*

Other reported treatments of demodex blepharitis include sulfur oil and steroids. An anti-parasitic gel (metronidazole) also has shown effectiveness as a treatment.

Another version of these mites (demodex brevis) can be found more generally in oil glands of the skin and eyelids, which also may contribute to blepharitis symptoms.

While presence of these tiny mites is common in everyone, researchers speculate that some people develop demodex blepharitis due to unusual allergic or immune system reactions leading to inflammation.

Eyelid Hygiene Relieves Blepharitis Symptoms

Use a cotton-tipped swab to apply cleaning solution recommended by your eye doctor. Rub gently around the edges of your upper and lower eyelids, but do not get cleaning solution in your eye.

Blepharitis can be difficult to manage because it is often chronic, meaning that it never goes away completely. Your eye doctor may recommend one or more of these steps involving good eyelid hygiene and massage:

• Apply a warm compress such as a washcloth to the outer eyelids.
• Cleanse the eyelids with a commercial lid scrub or other recommended product.
• Gently massage the outer eyelids.

A warm compress loosens the crust on your eyes and eyelids before you clean them. The warmth also can loosen any blocked residue in your eye's oil glands, caused by meibomianitis.

To use a warm compress:

• Wash your hands, then dampen a clean washcloth with warm water.
• Place the washcloth over your closed eyes for several minutes.
• Open your eyes, and then use fingers to rub gently around the outer eyelids in a circular motion. Don't press too hard on the eyeball.
• Follow your doctor's recommendations on how often to use a compress and how long it should be kept in place.

When you first begin treatment, your eye doctor may suggest that you do this several times daily, for about five minutes each time. Later on, you might apply the compress once daily for a few minutes.

Cleaning the eyelids is essential to blepharitis treatment. Your doctor will recommend what cleansing agent to use, such as warm water only, baby shampoo diluted with warm water or a special over-the-counter product made specifically for cleansing the lids.

To clean eyelids:

• Wash your hands, then dip a clean washcloth, cotton swab or gauze pad into your cleaning solution.
• Make sure you squeeze out any excess moisture.
• Gently wipe across your lashes and lid margin.
• Rinse with cool water.
• Repeat the process for your other eye, but use a different washcloth, swab or pad.

Your doctor may have you clean your lids several times daily to start, and then once daily thereafter. — GW

Posterior Blepharitis

Posterior blepharitis involves dysfunction of oil-secreting meibomian glands within the eyelids. The openings of these glands are at the inner edge of the eyelids, and oils secreted by the meibomian glands help prevent tear evaporation.

Also called meibomian blepharitis, meibomitis or meibomian gland dysfunction (MGD), posterior blepharitis reduces meibomian gland output or produces abnormal oily secretions. Symptoms of posterior blepharitis include inflamed and thickened eyelid margins, eyelid crusting and other symptoms that are often difficult to manage. With this type of blepharitis, tears can even look foamy.

Meibomian blepharitis sometimes is described as dry eye syndrome caused by meibomian gland dysfunction.

Rosacea blepharitis often is a component of ocular rosacea, which can cause eyelid inflammation linked to dysfunction of the skin's oil (sebaceous) glands. Acne rosacea is a common skin inflammation characterized by pimple-like bumps and facial redness — especially around the cheeks, nose, forehead and chin. As with certain forms of blepharitis, underlying causes of rosacea aren't well understood.

However, rosacea does appear linked to certain genetic tendencies and environmental factors, such as excessive sun exposure.

Clogged meibomian glands from posterior blepharitis also can cause a stye or chalazion to form. A stye, which is often uncomfortable, grows from an infected oil gland in the eyelid. A chalazion is a non-infected, usually painless nodule caused by inflammation of a blocked meibomian gland.

Is There a Cure for Blepharitis?

A complete blepharitis cure may not exist. But as explained above, good eyelid hygiene and prescription medicine are often effective in managing blepharitis, while warm compresses and lid massages can help unclog obstructed meibomian glands.

If you wear soft contact lenses, your eye doctor may prescribe RGP contacts instead or may recommend more frequent replacement of your soft contacts to reduce lens deposits that may be associated with your blepharitis. Depending on the severity of your symptoms, you may need to discontinue contact lens wear altogether for a while.

Blepharitis can cause inflamed eyelids, eye burning and dryness.

It's a good idea to minimize use of eye makeup, which can interfere with eyelid hygiene and massage treatments. If your doctor recommends an anti-dandruff shampoo for your scalp and eyebrows, make sure you keep the shampoo out of your eyes, to avoid irritation.

Also as mentioned above, certain eye doctors recommend nutritional supplementation with omega-3 fatty acids to improve function of the eyelid's oil glands.

Because blepharitis and dry eyes commonly occur together, your eye doctor may advise you to use over-the-counter or prescription eye drops to help relieve symptoms.

In severe cases of dry eye, especially without significant blepharitis, you may benefit from the insertion of punctal plugs in tear drainage channels to help increase the amount of lubricating tears on the surface of your eye. More moisture on the eye surface can make your eyes feel better and healthier.

Resources:

*Corneal manifestations of ocular demodex infestation. American Journal of Ophthalmology. May 2007.

The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Transactions of the American Ophthalmological Society. December 2008.

Blepharitis. Ophthalmology, 3rd ed. 2008.

Gina White, Liz Segre and Michael DePaolis, OD, also contributed to this article.

[Page updated October 27, 2009]