Blepharitis

Blepharitis is a common and often chronic inflammatory condition that affects the eyelids, particularly the margins where the eyelashes grow. This condition causes irritation, redness, and swelling of the eyelids, leading to uncomfortable symptoms that can significantly impact daily life. While blepharitis is rarely sight-threatening, it can be persistent and requires ongoing management to control symptoms and prevent complications.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. If you suspect you have blepharitis or experience persistent eye symptoms, consult an eye care professional for proper diagnosis and treatment.

Overview

Blepharitis, derived from the Greek words "blepharon" (eyelid) and "itis" (inflammation), is one of the most common eye conditions encountered by eye care professionals. The condition primarily affects the lid margins, where oil glands, hair follicles, and other structures are located. These areas become inflamed due to various factors, leading to the characteristic symptoms of the condition.

There are two main types of blepharitis: anterior blepharitis, which affects the front edge of the eyelid where the eyelashes attach, and posterior blepharitis, which affects the inner edge of the eyelid that touches the eye. Many patients have a combination of both types, known as mixed blepharitis. The condition can affect people of all ages but is more common in adults, particularly those over 50.

Blepharitis is often a chronic condition that requires long-term management rather than a one-time cure. While it can be frustrating to deal with, proper treatment and consistent eyelid hygiene can effectively control symptoms and prevent complications such as styes, chalazion, or corneal problems. Understanding the condition is the first step toward successful management.

Symptoms

Blepharitis symptoms can vary in severity and may fluctuate over time. Some people experience mild intermittent symptoms, while others have more persistent and bothersome signs. The symptoms typically affect both eyes but may be more noticeable in one eye.

Common Eye and Eyelid Symptoms

Visual and Functional Symptoms

  • Diminished vision - blurred or decreased visual clarity
  • Spots or clouds in vision - temporary visual disturbances
  • Light sensitivity - increased sensitivity to bright lights
  • Feeling of foreign body - sensation of something in the eye
  • Difficulty wearing contact lenses - increased discomfort with lens wear

Physical Signs

  • Crusty eyelashes - scales or crusts at the base of eyelashes
  • Loss of eyelashes - thinning or falling out of lashes
  • Misdirected eyelashes - lashes growing in wrong direction
  • Thickened eyelid margins - swollen and inflamed lid edges
  • Flaky skin around eyes - dandruff-like scales on eyelids

Morning Symptoms

  • Sticky eyelids upon waking
  • Difficulty opening eyes in the morning
  • Matted eyelashes
  • Increased discharge overnight

Causes

Blepharitis can result from multiple factors, often occurring in combination. Understanding these causes helps in developing effective treatment strategies and prevention methods.

Bacterial Causes

  • Staphylococcus bacteria: The most common bacterial cause, particularly Staphylococcus epidermidis and Staphylococcus aureus
  • Bacterial overgrowth: Normal skin bacteria multiply excessively in the eyelid area
  • Bacterial toxins: Byproducts from bacterial metabolism cause inflammation
  • Secondary bacterial infection: Bacteria infect already irritated eyelid tissues

Seborrheic Causes

  • Seborrheic dermatitis: Skin condition affecting oil-rich areas of the body
  • Malassezia yeast: Fungal organisms that contribute to seborrheic inflammation
  • Excessive oil production: Overactive sebaceous glands in the eyelid area
  • Dandruff: Scalp condition that often accompanies eyelid inflammation

Meibomian Gland Dysfunction

  • Oil gland blockage: Meibomian glands become clogged with thickened secretions
  • Poor oil quality: Abnormal composition of eyelid oils
  • Gland atrophy: Progressive loss of functioning oil glands
  • Inflammatory mediators: Chemical substances that promote ongoing inflammation

Environmental and Lifestyle Factors

  • Poor eyelid hygiene: Inadequate cleaning of eyelids and lashes
  • Contact lens wear: Chronic irritation from lens use
  • Eye makeup: Cosmetics that clog glands or cause allergic reactions
  • Environmental pollutants: Smoke, dust, and other airborne irritants
  • Digital eye strain: Reduced blink rate from computer use

Underlying Medical Conditions

  • Dry eye syndrome: Inadequate tear production or quality
  • Rosacea: Skin condition that commonly affects the eyes
  • Allergies: Environmental or contact allergies affecting the eyes
  • Hormonal changes: Menopause, pregnancy, or hormonal medications
  • Autoimmune conditions: Disorders affecting the immune system

Risk Factors

Several factors can increase the likelihood of developing blepharitis or make existing symptoms worse. Identifying these risk factors can help in prevention and management strategies.

Demographic Risk Factors

  • Age: More common in adults over 50 due to changes in oil gland function
  • Gender: Slightly more common in women, possibly due to hormonal factors
  • Genetics: Family history of blepharitis or related skin conditions
  • Ethnicity: Some ethnic groups may have higher predisposition

Skin and Eye Conditions

  • Seborrheic dermatitis: Inflammatory skin condition affecting oil-rich areas
  • Rosacea: Chronic skin condition often involving the eyes
  • Dandruff: Scalp condition that frequently coexists with blepharitis
  • Dry eye syndrome: Inadequate tear production or quality
  • Allergic conjunctivitis: Eye allergies that cause chronic inflammation

Environmental and Occupational Factors

  • Dusty or smoky environments: Exposure to airborne irritants
  • Low humidity: Dry air that worsens eye and eyelid dryness
  • Computer work: Reduced blink rate and eye strain
  • Contact lens wear: Chronic irritation and bacterial accumulation
  • Air conditioning: Dry air from HVAC systems

Lifestyle and Personal Care

  • Poor eyelid hygiene: Inadequate cleaning of eyelids and lashes
  • Heavy eye makeup use: Products that clog oil glands
  • Sharing eye cosmetics: Risk of bacterial contamination
  • Touching eyes frequently: Transfer of bacteria from hands
  • Old or contaminated cosmetics: Bacterial growth in makeup products

Medical and Medication Factors

  • Hormonal medications: Birth control pills, hormone replacement therapy
  • Isotretinoin use: Acne medication that affects oil glands
  • Immunosuppressive medications: Drugs that reduce immune function
  • Chronic illness: Diabetes, autoimmune conditions
  • Nutritional deficiencies: Omega-3 fatty acid deficiency

Diagnosis

Diagnosing blepharitis typically involves a comprehensive eye examination by an eye care professional. The diagnosis is usually made based on clinical signs and symptoms, though additional tests may be performed to determine the underlying cause or rule out other conditions.

Clinical Examination

The primary diagnostic approach includes:

  • Visual inspection: Examining the eyelids for signs of inflammation, scaling, and discharge
  • Eyelid margin assessment: Looking at the lid edges where most symptoms occur
  • Eyelash examination: Checking for debris, scaling, or misdirected lashes
  • Tear film evaluation: Assessing tear quality and quantity
  • Meibomian gland assessment: Examining oil gland function and blockage

Diagnostic Tools and Tests

Slit Lamp Examination

  • Provides magnified view of eyelid structures
  • Allows detailed assessment of lid margins and lashes
  • Helps identify type and severity of blepharitis
  • Can detect associated complications

Meibography

  • Specialized imaging of oil glands
  • Shows gland structure and function
  • Helps assess degree of gland dropout
  • Guides treatment decisions

Bacterial Culture

  • Identifies specific bacterial organisms
  • Determines antibiotic sensitivity
  • Reserved for severe or recurrent cases
  • Guides targeted antibiotic therapy

Classification and Types

  • Anterior blepharitis: Inflammation of front lid margin around lash follicles
  • Posterior blepharitis: Inflammation of inner lid margin involving oil glands
  • Mixed blepharitis: Combination of both anterior and posterior types
  • Seborrheic blepharitis: Associated with dandruff and seborrheic dermatitis
  • Staphylococcal blepharitis: Caused by bacterial infection

Differential Diagnosis

Other conditions that may be considered include:

  • Allergic conjunctivitis
  • Dry eye syndrome
  • Chalazion or stye
  • Trichiasis
  • Eyelid tumors
  • Contact dermatitis

Treatment Options

Treatment of blepharitis focuses on controlling symptoms, reducing inflammation, and preventing complications. Since blepharitis is often a chronic condition, treatment typically involves long-term management rather than a one-time cure. A combination of home care measures and medical treatments is usually most effective.

Home Care and Eyelid Hygiene

The foundation of blepharitis treatment involves consistent eyelid hygiene:

  • Warm compresses: Apply warm, moist heat for 10-15 minutes twice daily to soften crusts and open oil glands
  • Eyelid massage: Gently massage lids after warm compresses to express oil glands
  • Eyelid cleaning: Use diluted baby shampoo or commercial eyelid cleaners to remove debris
  • Regular cleaning routine: Maintain daily eyelid hygiene even when symptoms improve
  • Makeup removal: Thoroughly remove all eye makeup before sleep

Topical Medications

Antibiotic Treatments

  • Antibiotic ointments: Erythromycin, bacitracin, or mupirocin applied to lid margins
  • Antibiotic drops: For cases with associated conjunctivitis
  • Combination preparations: Antibiotic-steroid combinations for severe inflammation
  • Duration: Typically used for 1-2 weeks initially, then as needed

Anti-inflammatory Treatments

  • Steroid ointments: Short-term use for severe inflammation
  • Calcineurin inhibitors: Tacrolimus or cyclosporine for chronic cases
  • Anti-inflammatory drops: For associated dry eye symptoms
  • Immunomodulators: For cases with autoimmune component

Oral Medications

  • Antibiotics: Doxycycline or azithromycin for posterior blepharitis with meibomian gland dysfunction
  • Anti-inflammatory effects: Oral antibiotics also have anti-inflammatory properties
  • Duration: Usually prescribed for several weeks to months
  • Maintenance therapy: Low-dose long-term treatment may be needed

Advanced Treatments

In-Office Procedures

  • LipiFlow treatment: Thermal pulsation therapy to clear blocked oil glands
  • Intense pulsed light (IPL): Light therapy to reduce inflammation
  • Meibomian gland expression: Manual expression of blocked glands
  • BlephEx treatment: Mechanical cleaning of eyelids

Specialized Therapies

  • Tear supplements: Artificial tears or lubricating ointments
  • Omega-3 supplements: To improve oil gland function
  • Probiotics: For cases associated with systemic inflammation
  • Environmental modifications: Humidifiers, air purifiers

Treatment for Specific Types

  • Staphylococcal blepharitis: Antibiotic ointments and improved hygiene
  • Seborrheic blepharitis: Anti-dandruff treatments and gentle cleansers
  • Posterior blepharitis: Warm compresses, gland expression, oral antibiotics
  • Mixed blepharitis: Combination approach addressing all components

Prevention

While not all cases of blepharitis can be prevented, especially those related to genetic factors or underlying medical conditions, many preventive measures can reduce the risk of developing the condition or prevent recurrence.

Daily Eyelid Hygiene

  • Regular cleaning: Gently clean eyelids daily with warm water and mild cleanser
  • Remove makeup thoroughly: Never sleep with eye makeup on
  • Replace cosmetics regularly: Discard old eye makeup every 3-6 months
  • Use quality products: Choose hypoallergenic, fragrance-free eye cosmetics
  • Avoid sharing cosmetics: Don't share eye makeup or applicators

Environmental Modifications

  • Maintain humidity: Use humidifiers in dry environments
  • Avoid irritants: Stay away from smoke, dust, and chemical fumes
  • Protect from wind: Wear wrap-around glasses in windy conditions
  • Clean environment: Keep living and work spaces dust-free
  • Air filtration: Use air purifiers to reduce allergens

Lifestyle Modifications

  • Digital eye breaks: Follow 20-20-20 rule for computer use
  • Adequate sleep: Get 7-8 hours of quality sleep nightly
  • Stress management: Practice stress reduction techniques
  • Healthy diet: Include omega-3 fatty acids and antioxidants
  • Stay hydrated: Drink adequate water throughout the day

Eye Care Practices

  • Gentle handling: Avoid rubbing or touching eyes unnecessarily
  • Clean hands: Wash hands before touching eyes or applying products
  • Contact lens hygiene: Follow proper lens care and replacement schedules
  • Sun protection: Wear UV-protective sunglasses outdoors
  • Regular eye exams: Have routine eye checkups to detect problems early

Managing Underlying Conditions

  • Treat dandruff: Use anti-dandruff shampoos if you have scalp issues
  • Manage rosacea: Work with dermatologist to control skin condition
  • Address allergies: Identify and avoid allergic triggers
  • Control dry eyes: Use artificial tears as recommended
  • Hormonal balance: Discuss hormonal factors with healthcare provider

When to See a Doctor

Seek immediate medical attention for:

  • Sudden severe pain in eye with vision changes
  • Significant diminished vision or vision loss
  • Signs of serious infection: fever, spreading redness, severe swelling
  • Eye injury or foreign object in the eye
  • Severe light sensitivity with eye pain

Schedule an eye appointment for:

Consider professional evaluation if:

  • Home treatments haven't improved symptoms after 2 weeks
  • Symptoms worsen despite treatment
  • You develop new or concerning symptoms
  • You have underlying conditions like rosacea or seborrheic dermatitis
  • You experience frequent recurrences

Related Conditions

References

  1. American Academy of Ophthalmology. Blepharitis Preferred Practice Pattern. Ophthalmology. 2019;126(1):P56-P93.
  2. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient population. Cornea. 2012;31(5):472-478.
  3. Lindsley K, Matsumura S, Hatef E, Akpek EK. Interventions for chronic blepharitis. Cochrane Database Syst Rev. 2012;5:CD005556.
  4. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52(4):1930-1937.
  5. Putnam CM. Diagnosis and management of blepharitis: an optometrist's perspective. Clin Optom (Auckl). 2016;8:71-78.