• What is blepharitis?
• Treatment
  1. Lid Cleaning
  2. Lubricants
  3. Antibiotic Cream
  4. Diet and flaxseed oil
  5. Antibiotic tablets
  6. Steroid creams
• Eye lid Scarring
• Other causes of sore eyes &
  Drug treatment causing sore eyes
• healthy diet
• Blepharitis...a word document for patients
• blepharoconjunctivitis in children
• Blepharitis anterior & posterior
• Meibomian glands

Blepharitis is the medical term for inflamed eyelids. The inflammation is like eczema of the skin, with red, scaly eyelids. You may notice tired, or gritty eyes, which may be uncomfortable in sunlight or a smoky atmosphere. They may be slightly red, and feel as though there is something in them.

The eyelids have tiny glands in them, especially the lower lids. These glands make substances that mix with tears, and help the tears to spread across the eye.

A cartoon drawing of blepharitis: inflamed eyelids causing a sore eye

However, as you get older, and particularly if you have dry skin, these glands can block. As a result the glands do not make the chemicals that enables the tears to  spread evenly across the front of the eye.

As a result, the tears break up, and dry patches develop develop on the surface of the eye. These patches make the eyes feel sore or gritty. The eyelids evert during sleep.

The condition can be graded (ARVO 2010)

1. mild...noticed by the doctor only. No treatment needed, except may need to treat just prior to cataract surgery. A healthy diet with a little fish is helpful as below.

2. moderate

   • when the treatments below are needed...lid cleaning/antibiotic cream/lubricants.

   • more severe cases may need short courses of steroid creams for the eyelid.

3. Corneal involvement...may need more steroid and antibiotic tablets.

Blepharitis is not usually a serious condition. However, treatment is needed if you want to make the eye more comfortable.
In a very few people the blepharitis can be severe and damage the eyelids, and treatment can prevent more damage occurring.

The treatment is aimed at

1. unblocking the glands in the eyelid, which may be infected and inflamed, like acne on the face or a tiny boil by Lid Cleaning

2. replacing the tears if the eyes are dry with Lubricants (dry eyes and blepharitis may occur together: see below).

3. treating any infection present with Antibiotic Cream antibiotic cream

4. omega 3's...th long chain type that are in oily fish, are very helpful and important. Shorter molecule omega 3s such as flaxseed oil are probably helpful helpful

5. to treat infection and reduce the inflammation using Antibiotic tablets

6. steroid creams (only to be used by ophthalmologists/expert professionals)

7. if possible reduce doses of drugs likely to contribute to sore eyes, although this is often not possible as they are often essential. Proton pump inhibitors often contribute and their dose can be reduced.

The treatment should make your eyes more comfortable, but there is no magic cure. Even with treatment your eyes may remain a little sore, but no harm will come to them and there is nothing to worry about.

Start with lid cleaning, use antibiotic cream if this is not helpful. Tablets are for people with very troublesome sore eyes.

• Prepare the dilute baby shampoo: dilute baby shampoo, a tea-spoonful in one pint of warm (almost hot) water.

• Soak a cotton bud in this dilute baby shampoo. Clean the lids gently rubbing the cotton bud against the lid margin, and slightly on the inside of the lid, as in the diagram below. This is to remove scales and debris on the edge of the eyelid. The lower lid is the easiest to clean.

• Warm a face cloth in the microwave (not too hot) or soak it in hot water. (This is like the cloth used to clean hands in an Indian restaurant).

• Bathe the eyelids with face cloth over the closed eyelids for 4 minutes...just hold the ball over the eyelids ...this will loosen any scales on the eyelid. This thins the secretions in the eyelid glands.

• See a video demonstration.

• Start with the lower lid; repeat with the upper lid...this is a little harder, but not so important.

• repeat this at least twice a week, but more often if the blepharitis is very severe.

• ask the nurse in the eye clinic to show you this procedure.

• The warm bathing helps to soften up the scales first. It is preferable to boil the water first to sterilise it, and allow it to cool a little so it is almost hot.

• It may be two weeks for any improvement. It is safe to stop cleaning, but you may need to start again if the condition returns.

• gels such as ‘Gel Tears’ or ‘Viscotears’ are usually helpful

• drops such as ‘Sno-tears’ may help.

• if the eyes remain sore, preservative-free artificial tears may help. These are particularly useful for people with very dry eyes. Because they have no preservative they can be used more often, even every half-hour, without damaging your eyes.

• One example is 'Minims'  tears: the ampoules (mini-bottles) contain about 14 drops, and may last a day with practice. They are moderately expensive. Others include Clinitas soothe, Refresh, Celluvisc

These products are harmless: try and see if they help. You can buy them, but if you need them regularly they can be obtained on prescription. All patients should be tested for dry eyes, generally with a schimers test.

If the cleaning is not helpful, in addition your eyes may feel more comfortable if you use antibiotic ointment.

• Chloromycetin does not need a prescription from your GP

• fucithalmic does need a prescription

• Polyfax is another alternative

• Try creams for 1 month, and if it works continue for 3 months

• rub the cream into the eyelid margin

• these are safe. Only a few people develop allergies

• Sometimes the condition returns once the ointment is stopped, and you may need a repeat the treatment

• Some people benefit using the cream intermittently.

Diet has a significant effect on the ocular surface.

• Avoid saturated and transfats.

• Fish is said to be very helpful, and generally 2 portions a week are needed in the diet (75gm portions).

• Some fats such as fish oils and flaxseed oil   may be helpful, and patients have reported this to me. See. NHS Direct

This treatment is sometimes useful if the other treatments do not work. It is particularly effective if you have a skin condition, such as acne rosacea, or very dry skin, or if the edge of your eyelid stays red with many scales.

Antibiotic tablets are NOT suitable for everyone, particularly if you use several other tablets, are pregnant/breast feeding, or have stomach problems. You will need to discuss this treatment with your GP first. Oxytetracycline 250mg twice daily is usually used for 3 months, but not if pregnant.

Alternatives include doxycycline 50mg once daily [or erythromycin]. Professionals. see.

The benefit lasts several months after the treatment is stopped, but you may need to use further courses if the condition returns.

Steroid creams can be very helpful , but can be harmful.

• use only if advised by an ophthalmologists or equivalent expert professional.

• they may aggravate herpes simplex infections and increase eye pressure. The glaucoma may be severe. Long-term use must be carefully supervised.

• If they are used for a short time, they are generally very safe,

• the eye pressure is monitored: this is ESSENTIAL with prolonged use

• The other steps 1-5 above, that is lid cleaning, using lubricants regularly, and healthy diet are still needed: the steroids are generally best used if these steps are not sufficient.

• Use the cream, such as betnesol n, rubbing it into the lid margin. Use it daily for a week, then start to reduce frequency. Only the most severe cases will need regular use.

• Alternatively, start with the stronger creams such as betnesol n, then change to the weaker creams. (It is often easier just to reduce the frequency of use.)

Severe or persistent blepharitis can occasionally lead to scarring of the eyelid. This leads to lashes growing in towards the eye, which they may rub.

The lashes need to be removed, and there are other treatments if they are a frequent problem. Antibiotic tablets may help to eliminate the blepharitis.

If the eyelids become scarred eyelashes may start to grow in and irritate the eye; they will need to be removed every now and again.

• Your eyes should be checked for other conditions such as glaucoma, by an optometrist; occasionally new spectacles may make the eyes

• in some patients there a low grade infection of the eyelids. This is commoner is eczema patients

• occasionally there is a more serious infection of the eyelids (intensive treatment is needed)

• floppy eyelids causes sore eyes

• Many drugs cause sore eyes.

  • These include losec and zoton for hiatus hernia (often unnecessary), antidepressants, and many blood pressure lowering tablets, and frusemide. Proton pump inhibitors often contribute and their dose can be reduced.

  • The more drugs needed, the more likely you are to have sore eyes

  • people with diabetes often have sore eyes, perhaps because of all the tablets needed

  • peptic ulcers and hiatus hernias may necessitate proton-pump inhibitor treatment, and these probably make the eyes feel more irritable (my observation)

  • similarly smoking will put blood pressure up and make peptic ulcers and hiatus hernias more common, so indirectly make the eyes more sore

  • treatment for high blood pressure appears to make the eyes feel dry. A high blood pressure is harmful, and the effect of the drugs (the irritable dry eye) is not harmful, so it is safer to use the drugs. But if you could lower your blood pressure by increasing exercise, reducing alcohol and salt, this would be preferable.

• You may have another condition related to blepharitis:

  • You may have an allergy, particularly if the eyes are itchy: try Optichrom or another anti-allergy drop.

  • You may have dry eyes (or at least poorly spreading tears) and replacement tears may help, as described.

  • It may seem strange but a healthy diet helps prevent dry eyes and blepharitis. We regularly see young people who have a 'junk food' diet of beefburgers, no vegetables etc, with blepharitis.

  • omega 3 fats such as those in fish reduce 'dry eyes' by 30-60%. This healthy diet is discussed here. A healthy lifestyle is discussed in more detail here

  • You may have a thyroid problem..ask your doctor to check (a simple blood test)

  • Blepharitis and sore eyes may be caused by floppy eyelids, which is a common cause of chronic conjunctivitis 'vague ocular complaints of redness, irritation and. sometimes, a mucus discharge'. The upper eyelids everts during sleep.

• If your eyes remain red and very irritable an ophthalmologist will need to check your eyes in an Eye Clinic. ('Dry eyes' is the most likely cause).

• Blepharitis is not serious; some people whose eyes remain sore have little medically wrong, and are in fact anxious and unduly concerned. Your GP may be able to advise.

If you are a health professional and want to have a leaflet to give to give to patients, instead of this web page, see (now out of date) 400k Adobe PDF

Alternatively, this is a Microsoft Publisher (updated 2006) document click here, and you are welcome to download it and print copies. You are welcome to make changes for your patients (you can edit the leaflet in Microsoft Publisher).

You will need M Publisher 2000 to open and print the document. M Publisher is bundled as part of Microsoft Office. The only condition is that you let me know if there are any errors.
The document is 550k. The document can be printed out and photocopied to provide a double-sided leaflet 1/3 A4 size for your patients. The address is http://www.diabeticretinopathy.org.uk/leaflets/blepharitisweb.pub

This is a type of chronic conjunctivitis in children. Essentially conjunctivitis develops but does not get better with treatment, and there is also a blepharitis.

• marked follicles/papillae under the upper lid
• limbal oedema...limbitis
• vascularisation of the peripheral cornea
• corneal infiltrates develop
• corneal scars develop
• lots of blepharitis photo

mixed (mainly anterior) blepharitis

Generally needs

• ophthalmology referral
• extensive lid hygiene
• topical antibiotics
• systemic erythromycin if young (oxytetracycline or equivalent if bones developed/not pregnant)
• topical steroids
• should burn out at age 20y
• aggressive disease can cause serious problems such as corneal perforation

anterior

posterior

blepharitis may be anterior or posterior or mixed. Treatment is generally similar at present.

Glands can be

• normal
• atrophic/keratinised
• have thick secretions

secretions can be graded

• 0 = normal, clear oil
• 1=opaque, normal viscosisty
• 2=opaque, increased viscoity
• 3=inspissated like toothpaste

Secretions can be exmained by gently expressing the glands with a cotton bud, similar to cleaning as above. The secretions shown here are generally sterile.

Treatment

• warm compresses
• severe cases doxcycline ( if not pregnant etc)

grade 3 bloked meibonmian glands