What is blepharitis, what are the best treatments?

Blepharitis is the most common cause of tired, sore and dry eyes. 

Blepharitis is inflammation of the eyelids and is more common than cataracts or glaucoma. It must be controlled both before and after any eye surgery. Eye surgery does not cause blepharitis - everyone will have it at some stage in their life. It is non-infectious, rarely serious and the risk of developing long-term vision problems is extremely low.

Symptoms:

  • Tired, gritty, itchy or sore eyes.
  • Dry or watery eyes, or a burning sensation.
  • Crusty eyelids.
  • Inflamed eyelids.
  • Eyelids that stick together or can be difficult to open when you wake up.

There are two main types of blepharitis - anterior blepharitis and posterior blepharitis (also termed meibomian gland dysfunction).

Treatments include hot compresses, eyelid hygiene, artificial tear drops and Omega-3 dietary supplements . 

It is usually a long-term condition, meaning that once it is controlled, you will need to continue treatment to help prevent repeat episodes. There is no cure as of yet.

Treated blepharitis

Treated blepharitis

There are two main types of blepharitis:

  • Anterior blepharitis
  • Posterior blepharitis (or meibomian gland dysfunction, "MGD")

Anterior blepharitis is thought due to an overgrowth of bacteria helped in part by build up of debris (crusts) on the eyelid margins, or a response by the body against bacterial toxins. 

In posterior blepharitis there is blockage and resulting inflammation of the meibomian (oil) glands on the edge of the eyelids. Changes in the ratio of free fatty acids to cholesterol esters results in meibomian gland secretions with higher melting temperatures causing blockage of the gland opening. This results in less lipid (oil) secretion and so a reduced lipid layer of the tear film. This causes dry eye symptoms as the oil layer normally helps reduce tear film evaporation. 

Blepharitis can cause styes or Meibomian cysts (swollen lumps on the eyelids).

There is often no obvious reason why you have developed blepharitis at this particular time.

Anterior and posterior blepharitis, and a stye (bottom left)

Anterior and posterior blepharitis, and a stye (bottom left)

Blepharitis treatment:

1) Hot compresses

Blepharitis is difficult to cure, but the symptoms can be well controlled with good eyelid hygiene.

Hot compresses for 1-2 minutes are the mainstay of treatment. The key is moist heat as this helps to melt the oils that have blocked up the pores in the eyelids. You can use a face flannel with hot water held over the closed eye for 15 seconds before immersing in hot water again , although some people find special eye hot compresses such as the MGDRx eye bag, EyeSoothe Blepharitis Eye Mask or The Eye Doctor eye bag more effective. The recommended regime is four times a day for two weeks, then twice a day for a month, and twice a week after that. If you are using a simple hot compress with a face flannel then warm saltwater soaks are preferred as this is more isotonic and thus more comfortable and less likely to wrinkle the eyelid skin.

Steam from a hot shower or sauna can help. Special eyelid warming goggles such as Blephasteam Goggles can be very effective, but are expensive.

Eyelid massage¹,² should be done after the hot compress to unblock the openings of the Meibomian glands and reduce the bacterial load. Use a cloth or cotton bud with warm water or Blephasol Sensitive Eyelids Eye Lotion to gently wipe the edge of the eyelids. Gentle compression, not rubbing, of closed eyelids is ideal—with or without the use of a sterile eye pad/ wipe such as Blephaclean Sterile Pads or Lumecare Eyelid wipes. If blepharitis is severe, you can very carefully use a cotton bud to remove the cap of oil from the gland orifice - but be very careful not to touch your eye and do this only after being shown how to do this safely by your Ophthalmologist.

Unfortunately the treatment of blepharitis is frustrating as there is no immediate fix - you will need to do the above for 3-4 weeks before you notice any improvement, and will need to continue the lid hygiene long-term, so at least twice a week thereafter to prevent it from returning.

2) Lubricating eye drops:

These help make the eyes more comfortable.³ Recommended artificial tear drops include:

3) Blinking exercises ("think-blink")

Many people find blinking exercises to be surprisingly effective. The mechanical action of blinking helps Meibomian glands secrete their oil, however the rate of blinking decreases with age and near vision tasks such as computer use or reading.  A recommended regime to start with is to concentrate on blinking - so basically a big blink keeping the eye closed for about half a second, at least 20 times, four times a day. 

4) Omega-3 dietary/ food supplements:

A diet high in Omega-3 fatty acids can help control blepharitis symptoms. Omega-3 supplementation improves tear film stability and dry eye symptoms.

Omega-3 levels are particular high in foods such as some fish (Herring, Sardines, Mackerel, Salmon and Swordfish), and also Flaxseed, Chia seeds and Walnuts. 

Omega-3 dietary supplements include PRN Omega Eye, and Omax-3 which contain Omega-3 in triglyceride form that has the best absorption by the body. Most fish-oil based Omega-3 supplements are in the ethyl-ester form, which are less well absorbed and have a fishy aftertaste or odour. Omega-3 supplements have to be taken for at least 4 to 6 weeks before there is any improvement in blepharitis symptoms.

Vitamin supplements for age-related macular degeneration with Omega-3, such as Viteyes 2 Plus Omega-3, are also available. This is based on the AREDS2⁸ study and contains vitamins C & E, lutein, zeaxanthin, zinc and copper in addition to omega-3.

 

Hospital patient information on blepharitis:

There are many available, however the below are a selection of the best:

a) Moorfields Eye Hospital blepharitis advice

b) Oxford Eye Hospital information for patients

c) Massachusettes Eye and Ear website

 

References:

¹Key JE. A comparative study of eyelid cleaning regimens in chronic blepharitis. CLAO J. 1996 Jul;22(3):209-12.

²Arrúa M, Samudio M, Fariña N, Cibils D, Laspina F, Sanabria R, Carpinelli L, Mino de Kaspar H. Comparative study of the efficacy of different treatment options in patients with chronic blepharitis. Arch Soc Esp Oftalmol. 2015; 90(3):112-118.

³Bowman RW, Dougherty JM, McCulley JP. Chronic blepharitis and dry eyes. Int Ophthalmol Clin. 1987 Spring;27(1):27-35.

⁴Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc 2008;106:336-56.

⁵Bhargava R, Kumar P, Kumar M, Mehra N, Mishra A. A randomized controlled trial of omega-3 fatty acids in dry eye syndrome. International Journal of Ophthalmology. 2013;6(6):811-816.

⁶Macsai MS. Oleñik A, Jiménez-Alfaro I, Alejandre-Alba N, Mahillo-Fernández I. A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction. Clin Interv Aging. 2013;8:1133-8.

⁷Liu A, Ji J. Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. Med Sci Monit. 2014 Sep 6;20:1583-8

⁸Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013 May 15;309(19):2005-15