Blepharitis – Causes, Symptoms, Diagnosis, Treatment and Prevention

Blepharitis is a common cause of ocular discomfort and irritation for people of all ages, across all races and ethnic groups.

Generally, blepharitis is more of a symptomatic condition than a true health threat. However, if not well managed, it can be a source of constant distress that not only occurs once but frequently.

Keep reading to find out what this eye condition is, its cause, signs and symptoms, how to get rid of it and how to keep it from coming back.

What is Blepharitis?

Blepharitis is an eye condition that causes inflammation of the eyelid margin. It can either be acute or chronic, but the chronic cases are more common.

Eyelid margin thickening and prominent blood vessels are characteristics of chronic blepharitis. If the ulcerative debris is located only at the base of the eyelids, then probably it is acute blepharitis. (1)

In terms of anatomic location, the inflammation can either be at the anterior, posterior or may overlap these two regions. Anterior blepharitis affects the base of the eyelashes, the eyelid skin, and eyelash follicles.

Posterior blepharitis, in contrast, affects the inner edge of the eyelid that is in contact with the eyeball, meibomian glands, and gland orifices. (2)

Blepharitis can also be described as ulcerative or non-ulcerative. In ulcerative blepharitis, the inflammation is marked by small sore areas along the eyelid margin, with multiple suppurative regions producing pus and loss of eyelashes.

In non-ulcerative blepharitis, the edge of the affected eyelid is covered with small, white or gray scales. (3)

What are the signs and symptoms of blepharitis? (4)

  • The chief symptom is sore eyelids in which, one or both eyes may be affected.
  • Itching, burning, and crusting of the eyelids
  • Redness and stickiness of the eyes
  • Scaly skin around the base of the eyelashes
  • Tearing, blurred vision, and foreign body sensation on the affected eye
  • Eyes look inflamed and greasy
  • Sensitivity to light
  • Loss of eyelashes or eyelashes that grow abnormally in the wrong direction

The symptoms tend to be worse and the morning, and the crusting more prominent when waking up.

Most often, blepharitis and pink eye occur at the same time. A pink eye, also known as conjunctivitis, is characterized by red, bloodshot eyes.

Warning signs that require the immediate attention of an ophthalmologist include:

  • A significant change in vision
  • Substantial persistent pain
  • A sore eyelid that increases in size accompanied by redness and bleeding
  • If the signs and symptoms persist for more than two weeks

What Causes Blepharitis?

There are several possible causes of blepharitis depending on whether it is ulcerative or non-ulcerative. The most common cause is an overgrowth of bacteria that live on the base of the eyelids, known as Staphylococcus aureus. (5)

When the bacteria build up, they form a biofilm similar to the plaque that forms on teeth. The biofilm is a toxic environment that produces toxins which further cause inflammation of the meibomian glands at the eyelid margins.

Meibomian glands are responsible for supplying meibum, an oily substance that prevents eye dryness by providing lubrication and preventing evaporation of the tear film. Infection of meibomian glands therefore directly affects the quality and quantity of tears. (6)

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Since normal tears contain antibodies directed against bacteria and viruses, a lack of it means even more bacterial growth. These changes cause chronic inflammation and dry eye discomfort that can result in not only blepharitis but also a stye.

Another cause of blepharitis is seborrheic dermatitis, a common skin condition that causes scaly patches, skin redness, and dandruff. It commonly affects the oily parts of the body including the face, nose, eyelids and the chest.

When on the eyelids, it causes blepharitis. Seborrheic blepharitis can be brought about by a type of yeast known as Malassezia furfur, or it can also be a reaction to the fungus that lives in the sebum of the human skin. (7)

How is it diagnosed?

The clinical diagnosis of blepharitis is primarily based on the appearance of the eyes and symptoms. The first thing that a doctor does is history taking.

On the history of the condition, the doctor does not just concentrate on the major complaints. He or she will also ask for information that could give a clue to general health problems that may contribute to blepharitis.

Physical examination focuses on evaluating the eyelids, eyelid margin, eyelashes, gland openings, tear quality and quantity and the anterior part of the eyeball, using a slit lamp with a magnifying glass. The doctor can then make a diagnosis of the type of blepharitis then recommend the appropriate treatment.

Swabbing the skin for testing: occasionally, the doctor uses a swab to collect a sample of the crust that forms on the eyelid. The sample is then analyzed for the causative bacteria, fungi or evidence of an allergic reaction.

What are the treatment options for blepharitis?

The primary goal of treatment of blepharitis is to alleviate the symptoms, maintain good eyelid hygiene and eliminate triggers that precipitate the inflammation. (8)

1.Warm wet compressions

Warm compressions are applied to the affected eye for 5 to 10 minutes for two to four times daily. The purpose of the warmth is to soften the eyelid debris, dilate meibomian glands and allow secretions to run more freely.

After the compressions, the eyelid should then be washed gently with diluted baby shampoo or over the counter eyelid cleanser to remove any crusts still attached to the eyelids. (9)

For this self-care remedy, follow the following steps

  • Wash hands thoroughly with soap and running water
  • Dampen a cotton applicator or a clean washcloth with warm (nearly hot) water
  • Close eyes then apply (do not press hard) the warm compress over the eyelid for several minutes to give it time to loosen the crusty deposits. If the applicator cools, keep on re-warming it in the warm water, to maintain an adequate temperature to unplug any blocked glands and loosen secretions.
  • An alternative to a washcloth or cotton applicator is reusable microwave-friendly heat bags that can be purchased from an optician. Other than the convenience of warming with a microwave, another advantage is that they retain heat better, and thus keep a constant temperature over the eyelids.
  • Immediately afterward, moisten another washcloth or applicator with a cleanser of your choice and wash away the scales at the base of the eyelids.
  • For some cases, you may require to be more deliberate when cleaning the edges by gently pulling the eyelids away from the eye then gently rub the base of the lashes.
  • Finally, rinse the eyelids with warm water and pat dry with a clean face towel.
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To prevent spreading the infection from one eye to the other, use a different clean cloth or towel for each eye.

2.Gentle massage

This is particularly helpful with posterior blepharitis as it helps to push out oily fluid out of the meibomian glands. A cotton pad or a finger is used to massage the eyelids in small round patterns.

To massage, make sweeping movements upwards (if the lower lid is affected) or downwards (for the upper lid) with the eyes shut. Repeat 5 to 10 minutes, preferably after warm compressions and before cleansing. The movements should neither be too firm to hurt the eyeball nor too mild.

3.Stop using eye makeup

It is a good idea to keep eye make up on hold until the infection is resolved. Makeup makes it harder to clean the eyelids and can even be a way to reintroduce bacteria when one is putting in the effort to treat it.

4.Omega-3-fatty acids

Supplements like omega three fats keep meibomian glands healthy, and the eyes moist. A

diet rich in omega-3s is also particularly helpful if the blepharitis is associated with acne rosacea. These fats can be found in foods such as salmon, sardine, tuna, canola oil, flaxseeds, chia seeds and walnuts.

5.Tea tree oil

Tea tree oil (10) has anti-infective and wound healing properties that are effective against blepharitis, especially when it is caused by the troublesome Demodex mites and bacteria.

These mites are microscopic, and they live in the oil glands of the hair follicles. At the base of the eyelashes, Demodex mites consume epithelial cells, form dandruff which mechanically block the orifices of the meibomian glands and create a conducive environment for bacterial overgrowth.

Tea tree oil can be applied directly to the skin, but some people find it irritating. If that is the case for you, then it can be diluted with a carrier oil like coconut oil. Add two to three drops of tea tree oil to half a teaspoon of coconut oil on a clean cotton pad.

Then apply it to the affected eyelid(s). It will improve tear film stability as it unblocks gland orifices, soothes the dry, flaking eyelid and removes dandruff that may have collected.

If home remedies are not effective, the doctor may prescribe some medication.

Topical antibiotics (medicated eye drops, creams, and ointments) may be prescribed in case of acute blepharitis, anterior blepharitis or if there is the presence of a pink eye. They eradicate bacteria from the lid margin and can be applied for two to eight consecutive weeks.

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Oral antibiotics such as tetracycline and macrolides may be required for more severe cases that are not responsive to eyelid hygiene or are associated with acne rosacea.

Steroid eyedrops help to control inflammation.

If the eye dryness is too uncomfortable, then lubricating eye drops may also be recommended.

Blepharitis and contact lenses

If one develops blepharitis when using contact lenses, experts recommend that it is best to discontinue wearing them until the inflammation is successfully treated.

Wearing the contact lenses when the inflammation is active makes the bacteria stick to the lenses, and hence gaining access to other parts of the eye. This increases the risk of conjunctivitis and other serious eye diseases. (11)

Are there any possible complications of blepharitis?

Blepharitis is mainly a non-serious condition that is not sight-threatening. Most blepharitis cases are successfully treated, but a few may complicate. (12) It can progress to:

Meibomian cyst– a painless swelling that is prominent on the inner part of the eyelid, that occurs due to a blocked meibomian gland. It is easy to treat, but it makes the eye bulge and looks unsightly.

Chronic conjunctivitis- an inflammation of the thin clear tissue that covers the white part of the eye and the inside of the eyelid.

Styea localized infection of the edge of the eyelid that causes a tender, reddish pimple-like swelling with pus.

Scarring of the eyelids- occurs as a result of eyelid ulceration. It causes the eyelid to turn inwards towards the eyeball or outwards.  

Changes of the eyelashes

  • Madarosis- loss of eyelashes
  • Trichiasis- ingrowth or introversion of the eyelashes. Also, misdirection of the eyelashes towards the inner part of the eye.
  • Poliosis- loss of melanin pigment of the eyelashes that makes them appear white in color.

How to Prevent blepharitis

Blepharitis is mostly a condition that is chronic and characterized by exacerbations and remissions. That means that blepharitis can come back frequently, and hence is a recurring problem.

Although there is rarely a complete cure once it has set in, there are some key things that can be done to prevent it or stop the exacerbations.

Behavioral changes

Some fundamental changes that need to be done include:

  • Stop touching the eyes not unless it is absolutely necessary like when wearing contact lenses.
  • If blepharitis is a frequent problem, it would be good to give up eye makeup especially eyeliner. Makeup clogs oil glands and can even flake off to the tear film.
  • If the blepharitis is caused by Demodex mites, change bedding frequently. Do not allow the pillowcase to linger for more than three days without washing.
  • Make dietary changes to include anti-inflammatory foods that boost the immune system. Tomatoes, olive oil, green leafy vegetables, nuts, fatty fish, and fruits are full of active bio-compounds that fight off inflammations.

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