Blepharitis

This is a very common chronic, inflammatory condition of the eyelid margins (rim of the eyelid), with the severity and time course varying considerably. It is more common in people with certain skin disorders such as seborrhoeic dermatitis (scaly skin), rosacea (facial redness especially cheeks and nose) and eczema (itchy dermatitis).

There are two main types of blepharitis:

1. Anterior blepharitis

This is characterised by tiny crusts or flakes at the root of the eyelashes (a bit like dandruff). This attracts bacteria which can cause a chronic low grade inflammation. The bacteria can release chemicals which can irritate the surface of the eye.

2. Posterior blepharitis

Meibomian glands in the eyelids secrete an oily film onto the tears to reduce evaporation, and the gland openings (orifices) sit on the eyelid margin just behind the root of the eyelashes. Inflammation and blockage of the gland openings is known as posterior blepharitis or meibomian gland dysfunction. This condition results in a less stable tear film which "breaks up" too quickly, resulting in reduced lubrication to the surface of the eye.

Posterior blepharitis with inflammation of the eyelid margin and blockage of the meibomian oily glands

Symptoms of blepharitis

Whatever the cause or type of blepharitis there are several possible symptoms; most people will only have one or two of the following possiblities:

• Red inflamed eyelid margins
• Loss of eyelashes
• Sticky eyes, especially in the morning
• Gritty, itchy or burning
• Reflex tearing (see TEARING IN ADULTS)
• Meibomian gland cysts (see CHALAZION)
• Rarely a corneal ulcer (marginal keratitis)

Management

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 the function of the oily meibomian glands.

Lid hygiene involves 3 steps:

1. Warm compress, usually with a hot moist flannel, to soften crusts and liquefy the oily meibomian gland secretions.

2. 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.

3. Cleaning with cotton buds or purpose designed lid wipes from a chemist removes flakes / crusts and helps unplug the meibomian gland openings.

Lid cleaning upper eyelid margin

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 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. Occasionally topical antibiotic ointments, applied at night, are useful in reducing bacterial load. Steroid ointments are also often very helpful at treating inflammation in moderate to severe cases. More rarely, especially for posterior blepharitis, oral antibiotics eg doxycline, for 8-12 weeks can reduce lid inflammation.