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by Stuart Macfarlane

What is blepharitis?

Blepharitis is the generic name for a common condition affecting the eyelids. The term "blepharitis" is derived from "blepharon" (Greek for eyelids) and "itis" which refers to an inflammatory condition. Approximately half of all patients presenting for an eyetest have been found to suffer various degrees and types of blepharitis and it is the most common cause of dry eye

Blepharitis may be grouped into two main sub-types - anterior and posterior.  Anterior blepharitis may further be classified into bacterial, seborrhoeic and parasitic. Anterior blepharitis affects the outside front of the eyelid, where the eyelashes are attached. Posterior blepharitis affects the meibomian glands which are found in the inner eyelid (the moist part that makes contact with the eye) 

Various symptoms include watery eyes, filmy vision, frothy tears, red and swollen lid margins, crusting, foreign body or burning sensation, itchiness, dry eye and sensitivity to light (photophobia). Chronic, poorly managed blepharitis can cause conjunctivitis, changes to the lid margin, marginal keratitis (inflammation of the cornea) and styes. 

Anterior Blepharitis

Bacterial Blepharitis is commonly associated with Staphylococcus aureus or Staphylococcus epidermidis.  There is bacterial overgrowth at the lid margins resulting in the release of toxic bacterial by-products onto the tear film resulting in an inflammatory response.  Objectively there will be red, inflamed lid margins with dry, flaky debris along the margins and the absence of some lashes.  The mainstay of treatment is regular lid hygiene using warm packs followed by lid scrubs. Place a warm pack (a hot-water bottle or a microwaved rice pack will suffice) on the closed eyelids for several minutes. Then perform a lid scrub using either Sterilid foam or Systane Lid Care pads.  The foam is squirted onto the fingertips, gently rubbed along the lid margins and then rinsed or washed away.  This should be repeated twice daily for the first week, then daily.  In severe cases a course of antibiotic ointment may need to be prescribed. 

Seborrhoeic Blepharitis is due to the eyelid glands producing a excess of sebum. This results in greasy eyelashes as well as slight inflammation and greasy scales along the lid margins. Secondary bacterial blepharitis is often present as the oily deposits afford a good environment for bacterial infections to flourish. Again, ongoing lid scrubs are the basis of treatment and exacerbations may require a short course of anti-inflammatory ointment. When scalp dandruff or seborrhoea is present, a dandruff shampoo for the hair is recommended as well.

Demodex Blepharitis is from a minute parasitic mite called Demodex Folliculorum, which resides in the eyelash follicle. These mites are commonly found in dogs and are usually present in most people to a minor degree. However some people have an eyelid infestation of the mites which will cause blepharitis which can lead to scaly material not dissimilar to dandruff flakes around the eyelashes.  The eye can also be irritated and the margins inflamed and itchy.  Treatment is usually initiated in office with lid scrubs which can be performed with a diluted solution of tea tree oil (TTO). After instilling anaesthetic drops, a cotton bud is soaked in TTO and rubbed several times along the lid margins.    Alternatively a home treatment may be performed with a commercially available pad called Cliradex which is impregnated with tea tree oil. Perform this twice daily for the first week then daily, followed by washing the face and lids with water. The eye is usually more comfortable with the application of a mild anti-inflammatory ointment on the lid margins for the first week of treatment.  The condition usually resolves after a month of treatment.

Posterior Blepharitis  

Posterior Blepharitis is characterised by meibomian gland dysfunction.  The meibomian glands are sebaceous glands that produce the lipid or oily tears that form the top layer of the tear film.  This is the layer that helps stop tears from evaporating.  Depending on the severity of the condition these glands can be constipated, inflamed or not functional. So posterior blepharitis will result in varying degrees of the evaporative type of dry eye with associated symptoms of burning, scratchy eyes with a filming of vision. 

BlepharitisPosterior blepharitis can be related to rosacea. Treatment may need to be both topical and systemic.  Daily omega-3 supplements have been found to improve the quality of secretions from the meibomian glands after two months of use. Recalcitrant cases may require a several month course of oral tetracycline antibiotics.
Meibomian gland dysfunction is best treated by regular lid hygiene.  After or during showering perform a lid scrub using either Sterilid foam or Systane Lid Care pads.  The foam is squirted onto the fingertips, gently rubbed along the lid margins and then rinsed or washed away.  Then apply a hot pack like a wheat or rice bag (microwaved to around 42 degrees) to the eyelids for several minutes.  This should be followed by gentle expression of the eyelids to help clear the constipated glands. This is performed by rolling your finger towards the lid margin. 
Express of the meibomian glands can also be conducted in office with ongoing maintenance by the patient. The in office expression is usually performed after eyelid therapy with Blephasteam goggles. Generally your symptoms will be worse for the first few days since pro-inflammatory material is expressed from the glands, however, after several days there will be an improvement in symptoms. 
We have also had some success with Manuka Optimel drops. Based on Manuka honey, these drops have an anti-bacterial effect and help treat both blepharitis and meibomian gland dysfunction.

In summary; treatment for both forms of blepharitis involves keeping the lids clean and free of crusts. Warm compresses should be applied to the lid to loosen the crusts, followed by a light scrubbing of the eyelid with Systane Lidcare Pads or Sterilid foam.  Lidcare contains moistened pads for cleaning around the eyelashes. Sterilid is a cleansing foam designed to decrease the bacterial load of the lid margin.  Because blepharitis is generally a chronic condition, most patients must maintain regular eyelid hygiene routine for life.       

Author: Stuart Macfarlane