What causes blepharitis?
There are three main types of blepharitis: staphylococcal blepharitis, seborrhoeic blepharitis and meibomian blepharitis. All three types can cause similar symptoms.
People with blepharitis tend to have symptoms that flare-up from time to time. As mentioned, blepharitis is usually a long-term (chronic) problem, and its causes are usually chronic too. Typically, you rub your slightly sore and inflamed eyelids, further irritating them, creating a vicious cycle of more and more inflammation. This results in your eyelids becoming more sore and itchy, and the temptation to rub them even more increases, and so on.
This type of blepharitis is thought to be caused by a bacterium called staphylococcus. This bacterium is commonly found in low numbers on the skin, typically causing no harm. However, in some people, it seems that this bacterium causes a localised infection of the eyelids, resulting in blepharitis. It is not known exactly why this happens in these people.
Seborrhoeic blepharitis is closely linked with a skin condition called seborrhoeic dermatitis. In seborrhoeic dermatitis, the affected skin becomes oilier than normal and can become scaly. Seborrhoeic dermatitis typically causes bad dandruff and sometimes a rash on the face or upper body. The underlying cause of seborrhoeic dermatitis is not clear, but a type of yeast called Malassezia furfur is involved. However, it is not just a simple skin infection and it is not contagious. The yeast lives in the oil of human skin in most adults and is normally harmless. However, in some people the it seems to trigger an inflammatory reaction, causing the blepharitis.
This is also known as meibomian gland dysfunction. The tiny meibomian glands are located in the eyelids just behind the eyelashes. You have about 25-30 meibomian glands on each upper and lower eyelid. They make a small amount of oily fluid which is released on the inside of the eyelids next to the eye. This oily eyelid fluid forms the outer layer of the tear film which lubricates the front of the eye. It is thought that people with meibomian blepharitis have a slight problem with their meibomian glands and the fluid they produce. This may lead to eyelid inflammation. It also provides an explanation as to why people with meibomian blepharitis often have dry eyes, as their fluid may not be adequate to lubricate the eye.
Combinations of the above
In practice, it is often difficult to tell the difference between the above causes. Though, it is common for seborrhoeic blepharitis to occur together with meibomian blepharitis. Furthermore, skin which is inflamed in any way is more likely to become infected by staphylococcus. So, it is possible for all three causes to contribute to cases of blepharitis, with the main cause varying.
- The main symptom is sore eyelids. Both eyes are typically affected.
- The eyelids can look inflamed or greasy.
- Tiny flakes or scales may appear on the eyelids which look like flakes of dandruff. Crusts may develop at the base of eyelashes.
- The eyes may become sticky with discharge. In particular, the eyelids may stick together in the morning.
- One or more of the tiny glands of the eyelids (meibomian glands) may become blocked and fill with an oily fluid.
Typically, symptoms flare up from time to time, but you may have long periods without any symptoms at all.
Three other conditions are commonly associated with blepharitis. They are:
- Dry eye syndrome (keratoconjunctivitis sicca).
- Seborrhoeic dermatitis – mentioned above.
- Rosacea. Symptoms include facial flushing, spots, and central facial redness.
In most cases, blepharitis is uncomfortable but not serious or sight-threatening. Complications are uncommon, but can include:
- Chalazion (meibomian cyst). This is a painless swelling that is most prominent on the inside of the eyelid. It is due to a blocked meibomian gland. Although it is painless, it can cause the eyelid to bulge and look a little unsightly. It can easily be treated. However, sometimes a chalazion can become infected and painful.
- Stye. This is a painful infected swelling most prominent on the outside of the eyelid. This is due to an infection of the root of an eyelash.
- People who wear contact lenses may find their lenses feel uncomfortable during a flare up of blepharitis.
- Changes to the eyelashes (which mainly occur in severe and lchronic cases) include; loss of eyelashes (madarosis), misdirection of eyelashes towards the eye (trichiasis) and a discoloration of the eyelashes (poliosis).
- Eyelid ulceration and scarring. Though uncommon, this can cause the eyelid to turn inwards against the eyeball (entropion) or outwards (ectropion).
- Conjunctivitis (inflammation of the front of the eye). This may cause a sore, red eye with discharge or watering.
- Conjunctival phlyctenules. These are small (1-3 mm), hard, triangular, yellowish-white lumps surrounded by prominent but tiny blood vessels. If these lumps develop they normally occur on the lower part of the eye just below the cornea. They are made up of white blood cells that accumulate in response to bacterial infection.
- Corneal inflammation (keratitis), ulceration, and scarring. Though rare, this serious complication can affect sight. See a doctor urgently if you develop eye pain beyond the regular irritation or grittiness, or any loss of vision from the affected eye.
There is no one-time cure for blepharitis, as the inflammation tends to recur if you don’t keep up the treatment. However, with regular treatment, symptoms will usually ease and can be kept to a minimum. This tends to prevent flare-ups. The main treatment is regular eyelid hygiene. Other treatments that may be needed include antibiotics, steroid creams and treatment for associated conditions.
Regular eyelid hygiene
This is the most important aspect of treatment and prevention of blepharitis. The aim is to soothe the eyelids, unclog any blocked meibomian glands and wash away any stagnant oily secretions from these glands. This is a daily routine consisting of three parts – warmth, massage and cleansing. Make sure you remove any contact lenses before beginning.
The most common method is to press on the eyelids gently with a wash cloth soaked in very warm water for 5-10 minutes. To keep the cloth warm, keep running it under warm water. The purpose of warmth is to soften the skin and help dissolve any crusts around the eyelids. It also allows the oily secretions to flow easier. Warmth applied to the eyelids for about five minutes is sufficient to achieve this.
An alternative is to use a specially designed reusable heat bag to place over your eyes for about five minutes. The heat bag is warmed in a microwave. A heat bag will retain heat longer than a hot flannel. You can simply lie down and relax for five minutes with the bag over your eyes.
Massage the eyelids directly after applying the warmth. Massaging helps to push the oily fluid out of the tiny meibomian glands.
- Use your finger and sweep the fingertip from the inner corner of the eye along the eyelid to the outer corner of the eye.
- Start with the upper lid. Put the fingertip in the corner of the eye next to the nose, just resting on the eyelid above the lashes. Sweep the finger gently but firmly along the eyelid to the other side.
- Repeat this with the lower lid, placing the fingertip below the lashes and repeat the same motion.
- Repeat this action 5 to 10 times over about 30 seconds immediately after the warming.
You should always be careful with the massage pressure. It should be firm but relatively comfortable, but try not to press hard enough to hurt your
- eyeball beneath your closed eyelids. Massages should always be done with your eyes shut.
The final step is to clean the eyelids. This can be done in any of the following ways:
- Washing eyes with baby shampoo is the traditional way to clean the eyelids. Add a few drops of baby shampoo to a small cup of warm water so that the ratio of water to shampoo is 10:1. Use a cotton wool bud dipped in the shampoo and water solution, ensuring that you squeeze out the excess liquid from the cotton bud to stop it dripping into your eyes, which can cause irritations. Try to clean any crust at the base of the eyelids. Once your eyelids are clean, wash off the shampoo using a flannel or wash cloth.
- Another method is to use sodium bicarbonate. Add a teaspoonful to a cup of cooled water that has recently been boiled (to partially sterilise the water). This is applied using a clean cloth or cotton wool bud in the same manner.
- Special eyelid scrubs can be bought at some opticians/optometrists.
You should do the above routine – warmth, massage, clean – at least twice a day until symptoms settle. When the symptoms have eased, it is good to keep doing this routine once a day, every day, to prevent further flare-ups. If you are prone to blepharitis you can think of this as part of your daily routine, just like brushing your teeth, to keep symptoms away, or to a minimum.
Antibiotic eye ointment or drops may be advised for a while if an eyelid becomes infected. Antibiotic tablets are also commonly used for severely infected eyelids. A three month course of antibiotics is typically used in the treatment of blepharitis.
Other things to consider
Rubbing your eyelids often make inflammation worse, so try to have some self control and avoid doing this. As mentioned above, blepharitis commonly develops in people with seborrhoeic dermatitis, rosacea or dry eye syndrome. Treatment of these other conditions may also help to ease symptoms of blepharitis.
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