This is a common chronic, inflammatory condition of the eyelid margins of varying severity. It can be associated with certain skin disorders such as seborrhoeic dermatitis, acne rosacea and eczema.
There are two main types of blepharitis, which regularly co-exist:
Anterior blepharitis
Chronic low grade inflammation often associated with staphylococcal bacteria and characterised by tiny crusts or flakes at the root of the eyelashes, which can often be visualised using a pen torch light.
Anterior blepharitis: Magnified view of the upper eyelid with prominent crusting at the base of the eyelashes.
Posterior blepharitis (meibomian gland dysfunction)
Inflammation and blockage of the oily gland openings, located just behind the eyelashes; also known as meibomian gland dysfunction. This condition causes an unstable tear film (only apparent on slit lamp examination) which “breaks up” too quickly, resulting in reduced ocular surface wetting.
Posterior blepharitis: Inflammation results in dilated blood vessels in the posterior lid margin and blocked meibomian gland openings.
Another important cause of blepharitis, which can often be overlooked, is eyelid Demodex mite infestation. Demodex blepharitis is more likely to be present in individuals with facial rosacea. Demodex folliculorum, which is found in the eyelash follicle, causes anterior blepharitis with typical cylindrical dandruff visible at the root of the lashes. Demodex brevis, which burrows deep into sebaceous and meibomian glands, is associated with posterior blepharitis and can lead to meibomian gland dysfunction and keratoconjunctivitis.
Most patients with blepharitis will have one or more of the following symptoms:
- Red inflamed eyelid margins
- Loss of eyelashes (madarosis)
- Sticky eyes, especially in the morning
- Gritty, itchy or burning
- Reflex tearing
- Meibomian gland cysts (chalazion)
- Rarely a corneal ulcer (marginal keratitis); additional symptoms of photophobia and requires a specialist opinion
Chronic blepharitis: Red inflamed lid margins with loss of eyelashes, especially in the lower lid.
The main treatment for blepharitis from any cause is eyelid hygiene to clean the lid margins. This removes flakes and crusts, reduces the bacterial load and improves meibomian gland function. Lid hygiene involves 3 steps:
- Warm compress, usually with a hot moist flannel, to soften crusts and liquefy the oily meibomian gland secretions
- Massage to express the oily meibomian glands and improve the stability of the tear film. The upper lids are massaged downwards and the lower lids upwards
- Cleaning with cotton buds (using a pinch of bicarbonate in an egg cup of cooled boiled water) or purpose designed lid wipes from a chemist removes crusts and helps unplug the meibomian gland openings. In Demodex blepharitis tea tree oil treatments eg 50% tea tree oil diluted using Macadamia nut oil for use around the eyes, are effective in eradicating mites and reducing eyelid/ocular surface inflammation.
Eyelid hygiene initially should be performed every morning and night for several weeks to get the blepharitis under control. Once symptoms improve a maintenance regime of daily cleaning is required to prevent flare ups.
Artificial tear drops eg hypromellose, liquifilm , systane ultra can improve comfort, especially during the early stages of performing eyelid hygiene (which often takes several weeks to take effect). If ocular lubricants are required more than four times a day then it is recommended that a preservative free preparation is used eg celluvisc 0.5% or hylotears. Occasionally topical antibiotic ointments eg fucithalmic or chloramphenicol applied at night for one week, are useful in reducing bacterial load. Steroid ointments eg maxitrol are also often very helpful at treating inflammation in moderate to severe cases but should only be prescribed on the recommendation of a specialist. More rarely, especially for posterior blepharitis, oral antibiotics eg doxycline, for 8-12 weeks can reduce lid inflammation.
Beware:
- Sebaceous gland carcinoma can masquerade as prominent unilateral blepharitis, or rarely can present as recurrent chalazia in the same location
- Reduced vision or photophobia suggests significant corneal involvement and requires an ophthalmological opinion