Blepharitis Blepharo- keratoconjunctivitis (& eyelid ocular rosacea)
David Kinshuck & colleagues
These are different names for the same condition.
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. There may be fungi in the lids Eye 15, or demodex mite.
The glands in the eyelids shown in purple
This thin layer of tears lubricates the eyes, stops them drying out, and keeps them comfortable.
Evenly spreading tears: a comfortable 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.
Blepharokeratoconjunctivitis (ocular rosacea) may occur in adults or children. There is often a long delay getting treatment.
- Lid margin may not be inflamed, lids..anterior or posterior involvement.
- may be asymptomatic
- Chalazia..posterior lid
- hypersensensitivity..anterior lid
- lid...styes...staphyloccus contributes.
- On the lids there is crusting, telangiectasia, phlyctentules papillary hyperplasia, hyperaemia
- corneal ...crystal, marginal infiltrates, punctate epitheliopathy, axial corneal scar, vascularisation, phlyctenules, thinning.
- need to exclude Molluscum, allergic, chlamydia, ligneous conjunctivitis
- there may be skin flakes; collarettes suggest demodex as below
This may cause or contribute to the blepharitis
- if there are collarettes, scrape lid and look for demodex
- recurrent chalazion scrape margin similarly
- there may be keratinisation
- 2 types of mite,
- one causes the blepharitis
- one causes chronic chalazion/ multiple chalazion in children
- demodex is linked to rosacea and loss of lashes
Poorly spreading tears: dry patches develop on the surface of the eyes making them sore.
The condition can be graded (ARVO 2010)
- 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.
- when the treatments below are needed...lid cleaning/antibiotic cream/lubricants.
- more severe cases may need short courses of steroid creams for the eyelid.
- Corneal involvement, with pannus (blood vessels growing in on to the surface of the cornea)..may need more steroid and antibiotic tablets (see treatment for children below)
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.
Start with lid cleaning, use antibiotic cream if this is not helpful. Tablets are for people with very troublesome sore eyes.
The treatment is aimed at
- unblocking the glands in the eyelid, which may be infected and inflamed, like acne on the face or a tiny boil by Lid Cleaning
- replacing the tears if the eyes are dry with Lubricants (dry eyes and blepharitis may occur together: see below).
- treating any infection present with Antibiotic Cream antibiotic cream
- omega 3's... the long chain type that are in oily fish, are very helpful and important. Omega 7 as in See Buckthorn oil may help
- to treat infection and reduce the inflammation using Antibiotic tablets
- steroid creams (only to be used by ophthalmologists/expert professionals)
- 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 often be reduced.
Treatment measures include
- Blephamask (see Altacor)..some people find these heated masks very helpful, use for 5 minutes wice daily.
- Tea Tree Oil. Dilute it 50% (half oil, half water) and use once daily as the cleaning solution. There may be in infection of the eyelid with an invisible mite demodex. It is likely this is killed by ointments such as VitApos. Even with treatment your eyes may remain a little sore, but no harm will come to them and there is nothing to worry about. See
- Alternatively cliradex helps but is very expensive, and probably no better
- Decontaminate skin with iodine or hibiscrub
- ?take samples from lids or chalazion to look for demodex
- clean the whole body with soap and if necessary a staph aureas decontamination. this is n preoperative routine:
- Nasal decolonisation BACTROBAN (Mupirocin 2%) nasal treatment. This is used 3 times daily for 5 days. A small amount, about the size of a match head, is applied to a cotton bud or a gloved finger and then applies to the inside of each nostril (apply to the front part of the nostril). The nostrils should then be closed by pressing the sides of the nose together; this will spread the ointment through the nostrils.
- Antibacterial bodywash OCTENISAN body wash. Octenisan body wash should be used in place of other soap/skin washes every day for a shower, bath or wash in the 5 days running up to admission. The hair should be shampooed with it on 2 occasions during this time.
- Soak a tissue in hot water (not hot enough to burn), and press it against the upper and lower eyelids. This helps to unblock the glands. Bathe the eyelids for 5 minutes. The bottom lid is easier to bathe and usually the most important to clean.
- After 5 minutes massage the eyelids, upper and lower, with the tissue, gently wiping or massaging them.
- Repeat this at least twice a day for a few days, then twice a week.
- Ask your clinic nurse to show you this procedure.
- It may take two weeks for any improvement. It is safe to stop cleaning, but you may need to start again if the condition returns.
- an 'eye bag' may help BJO14
- 'Tea tree oil' , dlute it 50% (half oil, half water) and use once daily as the cleaning solution. helps some patients 2010. Use tea tree shampoo on the hair, and dilute it and use it as the eyelid cleaning solution.
- Ocusoft wipes help.
- use a cotton bud and clean margin with diluted tear tree shampoo.
- use a hot compress (hand towel, like in an Indian restaurant) soaked in hot water and bathe lid for a few minutes
- rub antibiotic into margins for more severe cases (Polyfax, chloramphenicol, or Fucithalmic or azithromycin)
- Doxycycline 100mg a day for 1 month, then 50mg a day. Side effects..skin (sunburns easily), stomach problems, drug interaction, not suitable for children/pregnancy
drops are needed for comfort
Lubricants can helpful to both assist the spread of your own tears and lubricate the eye, and replace tears if you have 'dry eyes'.
- gels such as 'Gel Tears' or 'Viscotears' are usually helpful
- 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.
- Preservative free drops include Hylofort, Hylocare, Clinitas soothe, and others
- Creams at night such as VitApos will help to kill the Demodex mite if it is present.
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 schirmers test.
antibiotic cream such as chloramphenicol may help blepharitis
If the cleaning is not helpful, in addition your eyes may feel more comfortable if you use antibiotic ointment.
- Colorimetry does not need a prescription from your GP
- chloramphenicol 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
- Azithromycin cream can help resistant cases. Much shorter courses required.
- Sometimes the condition returns once the ointment is stopped, and you may need a repeat the treatment
- Some people benefit using the cream intermittently, but this is not ideal as resistance may develop.
Diet has a significant effect on the ocular surface.
- Avoid saturated and transfats. See. NHS Direct
- Fish is said to be very helpful, and generally 2 portions a week are needed in the diet (75gm portions).
antibiotic tablets, e.g. doxycycline
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. Doxycycline 100mg once daily (keepout of sun if using) [or erythromycin] once daily for one month, then 50mg once daily for 2 more months. Professionals. see. An alternative: erythromycin dose 250/400 4 times a day (lower dose after 4 weeks?).
Azithromycin tablets can help, a very short course.
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 rubbing it into the lid margin. Use it daily for a week, then start to reduce frequency (NOT long term).
- Alternatively, start with the stronger creams such as betnesol, then change to the weaker creams. (It is often easier just to reduce the frequency of use.)
- Cyclosporine cream, such as Restasis, can help very resistant cases.
- Ask GP if it is possible to stop or reduce dose of omeprazole/lansoprazole, as these reduce tear secretions and make the eyes more sore.
- Hyloforte every 1-4 hourly
- Occ VitApos night.
- Vitamin d (perhaps from a chemist or supermarket).
- Lid hygiene..meibopatch (microwavable heated eye pads)..hot bathing.
- Clean lids with very dilute tea tree oil in clean water using a cotton wool bud or tissue.
- Lots of walking (1-2 hours a day physical exercise helps many conditions), and keep weight down.
- No junk food, plenty of oily fish, 7 portions of vegetables a day, e.g. 2 salads a day.
- Omega 3 supplements.
- Bloods tests for diabetes and thyroid (FBC, crp, U & Es, Lipids, HbA1c, TSH)
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).
- Many drugs cause sore eyes.
- These include lansoprazole (Zoton) omeprazole (Losec) and other proton-pump inhibitors and used for hiatus hernia, anti-depressants, and many blood pressure lowering tablets, and furosemide. Proton pump inhibitors may be needed for a while but may become unnecessary. Also, their dose can be reduced (often).
- 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.
- Rarely there will be scarring of the cornea and blood vessels growing on the cornea, and this is more serious: see treatment for children below. Treatment will include steroid drops initially; doxycycline if well tolerated; and Cyclosporine or tacrolimus long term so the dose of steroid drops can be reduced; very healthy diet, lid 'cleaning' as above.
- 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 generally 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.
- Rosacea may be present...look for red cheeks. Doxycycline 100mg once a day for 16 weeks if not pregnant and otherwise well.
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).
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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
- aggressive disease is unusual but can cause serious problems such as corneal perforation
- Eye 16
- Eye 16 JEADV 17
- Topical antibiotic such as occ chloramphenicol or occ azithromycin
- Long term azithromycin may help
- for the lids consider occ metronidazole.
- Healthy diet
- flaxseed oil 2g/day for 6 weeks, then alternate days for 6 months
- lid cleaning
- Systemic treatment
- Topical steroid
- If steroids drops are used, check eye pressure
- corneal involvement: dexamethasone preservative free 0.1% frequently but reducing quickly
- Topical tacrolimus (Protopic twice a day) in addition for severe corneal involvement (or steroid sparing).
- Average 2y treatment, 12% treatment failure
- superficial keratitis
- corneal vascularisation
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.
Gland orifices pout, eyelid margin is hyperaemic, with telangiectasia and clogged up glands, which may ulcerate, and there may be skin flakes ('dandruff'). Chronic blepharitis may lead to trichiasis and marginal keratitis and peripheral corneal neovascularisation.
Glands can be
- have thick secretions
secretions can be graded
- 0 = normal, clear oil
- 1=opaque, normal viscosity
- 2=opaque, increased viscosity
- 3=inspissated like toothpaste
Secretions can be examined by gently expressing the glands with a cotton bud, similar to cleaning as above. The secretions shown here are generally sterile.
- warm compresses
- severe cases doxycycline (if not pregnant etc)
Rosacea in children: Blepharo-keratoconjunctivitis
- Blepharo-keratoconjunctivitis (Bkc) may be childrens rosacea, probably is
- Red photphobia, discharge, rubbing, watering, pain
- Asian, age3-5, unilateral, multiple rcurrences Lid, blepharitis, chalazia, styes, folliculitis
- Styes = bkc not allergic
- Hyperaemia, papillary, phlycten, (no follicles with allergy)
- Corneal, marginal, pee (punctate epithelial erosions), subepithelial lesions
- Brisk improvement with steroids
- clean lid margin as above
- Treat infection, topical oral, azithromycoin or erythromucin 10 d,
- keratopathy fml 4 times day, have abottle spare if eye gets red, and see 2 d later,
- some shildren will neem more steroid drops
- Topical azithromycin bd bd twice a day 3 d
- For 2 weeks and may be carry on, occasional long term erythromycin, occasional long term steroid..watch iop
- Why is this not allergic.... no other atopy, chalzia, follicles, pattern of kerotpathy,
- Occasional hsv keratitis
Roasacea in adults
- Often unilateral, often skin normal
- Severe cornea disease can perforate: pinpoint perforation sometimes
- Long term tetracycline, doxycycline (keepout of sun if using), erythromycin
- doxycycline 100 od 3m, then 50 mg (keepout of sun if using)