Blepharitis

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On this page… What is blepharitis? | How is it diagnosed? | Medical Treatment | Surgical Treatment | FAQs and Links | MG Expression ↓

What is it?

Blepharitis is inflammation of the eyelid margin.

Crusting of the eyelashes in anterior blepharitis

Crusting of the eyelashes in anterior blepharitis

The eyelid margin

Although the eyelid margin is very narrow there are two quite separate and important zones.

The anterior zone contains the roots of the eyelashes. The posterior zone contains small oil glands known as the meibomian glands.

Types of blepharitis

There are three types of blepharitis:

  • Anterior blepharitis
  • Posterior blepharitis
  • Mixed blepharitis

Anterior blepharitis

Anterior blepharitis affects the front edge of the eyelid and eyelashes. This type of blepharitis is similar to dandruff; the eyelid margin becomes greasy and crusted. Bacterial infection is common. In severe cases eyelash loss occurs.

Posterior blepharitis

Posterior blepharitis, also known as meibomianitis, affects the back edge of the eyelid and the meibomian glands. Posterior blepharitis is like acne. The meibomian gland secretions thicken and the glands become blocked and inflamed. Infection is rare.

Mixed blepharitis

Mixed blepharitis is inflammation of the entire lid margin.

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How is it diagnosed?

Buttery meibomian secretions in posterior blepharitis

Buttery meibomian secretions in posterior blepharitis

In severe cases blepharitis is easy to diagnose, even with the naked eye. In mild disease the diagnosis is made with the slit lamp microscope.

Changes are present in the eyelid and may also be apparent in the tears and cornea.

Changes in the eyelid

The key changes on the eyelid margin are:

  • Greasiness of the skin
  • Crusting of the lashes
  • Plugging of the meibomian glands
  • Altered oily secretions
  • Dilated blood vessels, known as telangectasia
  • Eyelid cysts
  • Scarring of the eyelid margin – pits and twisting

Changes in the tears

Severe blepharitis with marked inflammation of the eyelid margin

Severe blepharitis with marked inflammation of the eyelid margin

Key changes in the tears include:

  • Thinning and “breaking up” of the oily layer. The “break-up time” of the tear film can be assessed by staining the tears with fluorescein dye and observing how long the oily layer remains stable before suddenly thinning.
  • “Blobs” of thickened oil

Changes in the cornea

Thinning of the oily layer of the tears (dark patches) and loss of epitheial cells of the cornea (bright dots)

Thinning of the oily layer of the tears (dark patches) and loss of epitheial cells of the cornea (bright dots)

Common corneal changes include:

  • Patchy loss of cells of the epithelium, known as punctate keratopathy
  • Inflammatory, “marginal”, ulcers

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Medical Treatment

Severe blepharitis with marked inflammation of the eyelid margin

Severe blepharitis with marked inflammation of the eyelid margin

Blepharitis is a chronic condition that can never be cured but can usually be significantly improved.

The key to successful treatment is correctly diagnosing whether the eyelid changes are anterior, posterior or both.

Anterior blepharitis

Anterior blepharitis is a dandruff-like condition that responds to treatments similar to those used to treat dandruff. These include:

  • Gentle cleaning of the lid margins with a “no-tears” shampoo FOR A SHORT TIME
  • Old fashioned treatments such as weak bicarbonate solution work well
  • Sterilid® and Lidcare®
  • Short courses of antibiotics

Posterior blepharitis

Posterior blepharitis is an oil gland dysfunction. Inflammation without infection is common. Posterior blepharitis responds well to therapies used to treat acne such as:

  • Hot compresses
  • Eyelid massage
  • Anti-inflammatory drugs such as Doxycycline
  • Steroid eye drops, ointments and injections
  • Manual expression
  • Omega-3

Omega-3

Omega-3 supplementation is a recognised treatment for posterior blepharitis, reducing inflammation and providing the meibomian glands with essential fatty acids with which to synthesise the oily gland secretions.

Our food contains two types of fatty acids known as Omega-3 and Omega-6. They are essential for our health and as our body cannot manufacture them, must be found in our diet.

Omega-3 is a “good fat” which is used by the body to both produce anti-inflammatory compounds and block the activity of inflammatory mediators. Omega-6 is a “bad fat” that promotes inflammation. It is not always possible to decrease dietary Omega-6 intake, but adding Omega-3 to your diet is a very effective way to reduce inflammation.

Beef, dairy products and the vegetable oils found in biscuits and snack foods are high in omega-6. Because our diet is rich in animal and vegetable fats, many New Zealanders suffer from Omega-3 deficiency.

The best sources of Omega-3 are:

  • Dark, oily, coldwater fish such as salmon and tuna
  • Flaxseed oil, available from health food shops
  • Capsules of fish and flaxseed oils, available from pharmacies

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Surgical Treatment

Chalazia, blocked meibomian glands, in both the upper and lower eyelids

Chalazia, blocked meibomian glands, in both the upper and lower eyelids

Some patients with blepharitis require surgery for chalazia.

Chalazia

Posterior blepharitis may result in total obstruction of the openings of the meibomian glands. The oily secretions cannot escape and form cysts in the lid called “chalazia”.

Incision and curette

Chalazia can be treated by opening the swollen gland and removing the oily contents.

Incision and curette is a minor operation that can be performed at Dr McKellar’s rooms using local anaesthesia.

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FAQs and Links

Is blepharitis contagious?
No.

Can blepharitis be cured?
Not totally, but treatment can dramatically reduce symptoms.

Recommended links

Blepharitis →

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Meibomian Gland Expression

Expressing the meibomian glands with cilia forceps - this patient has thick buttery secretions

Expressing the meibomian glands with cilia forceps – this patient has thick buttery secretions

Manually expressing the contents of the meibomian glands helps diagnose meibomian gland disease (MGD) and is a proven therapy for posterior blepharitis and evaporative tear dysfunction. It’s not “sexy” but it does work.

Why is it done?

Thick stagnant secretions plug the meibomian gland openings, irritate the eye and allow the tears to evaporate. Emptying the glands allows them to make fresh, better-quality secretions.

Technique

A paddle or “tweezers” are used to compress the eyelid and squeeze out the contents of the meibomian glands.

Anaesthetic

The eye and eyelid are anaesthetised with eyedrops and the procedure is not usually painful. If you find the squeezing uncomfortable take paracetamol before your appointment.

What happens?

The amount and type of secretions expressed vary enormously. The gland contents may be clear, cloudy, buttery, gelatinous or toothpaste-like. Sometimes nothing comes out. Frothy secretions are common. Patients who have taken anti-acne therapy often have small plugs of solid “oil” blocking the gland orifices.

What does it all mean?

Generally the thinner the secretions and the more glands that can be expressed, the better. Repeated expression usually results in thinner and thinner secretions.

Frequency of expression

Some patients need just a single treatment, others benefit from regular expression. Most quickly work out how often they need to be seen.

What will you notice?

You may notice a significant improvement within a few days but usually it takes more than one expression before the glands recover.

Who can express your meibomian glands?

Most optometrists and ophthalmologists have the needed skills and training or can find advice on how to help you here.

Can you express the meibomian glands yourself?

When the secretions are thick it is very difficult to squeeze out the secretions yourself. When the secretions become thinner it is possible for patients to express the glands themselves. See MGD self-expression for more details.

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