Blepharitis

Overview
Blepharitis is inflammation of the eyelids. It is characterized by inflammation of the eyelid margins. Blepharitis usually causes redness of the eyes and itching and irritation of the eyelids in both eyes. Its appearance is often confused with conjunctivitis and due to its recurring nature it is the most common cause of "recurrent conjunctivitis" in older people. It is also often treated as 'dry eye' by patients due to the gritty sensation it may give the eyes - although lubricating drops do little to improve the condition.

There are two types of Blepharitis:
 * 1) Anterior blepharitis affects the front of the eyelids near the eyelashes. The causes are seborrheic dermatitis (similar to dandruff) and occasional infection by Staphylococcus bacteria.
 * 2) Posterior blepharitis affects the back of the eyelids, the part that makes contact with the eyes. This is caused by the oil glands present in this region. It is by far, the most common type of blepharitis.

Staphylococcal blepharitis
Staphlycoccal blepharitis is a type of external eye inflammation. As with dandruff, it is usually asymptomatic until the disease progresses. As it progresses, the sufferer begins to notice a foreign body sensation, matting of the lashes, and burning. Usually, the primary care physician will prescribe topical antibiotics for staphylococcal blepharitis. Unfortunately this is not an effective treatment.

This ailment can sometimes lead to a chalazion or a stye.

Seborrheic blepharitis
Seborrheic blepharitis, the most common type of blepharitis, is usually one part of the spectrum of seborrheic dermatitis seborrhea which involves the scalp, lashes, eyebrows, nasolabial folds and ears.

Treatment is best accomplished by a dermatologist.

Posterior blepharitis or Rosacea associated blepharitis
The most common type of blepharitis is often found in people with a rosacea skin type. The oil glands in the lid (meibomian glands) secrete a modified oil which leads to inflammation at the gland openings which are found at the edge of the lid.

Treatment and management
The single most important treatment principle is a daily routine of lid margin hygiene as described below. Such a routine needs to be convenient enough to be continued lifelong to avoid relapses as blepharitis is a lifelong condition.

A typical lid margin hygiene routine consists of 3 steps:

1. Softening of lid margin debris and oils:

Apply a warm wet compress to the lids - such as a washcloth with hot water - for about 2 minutes. 2. Mechanical removal of lid margin debris:

At end of shower routine, wash your face with a wash cloth. Use facial soap or non-burning baby shampoo (make sure to dilute the soap solution 1/10 with water first). Gently and repeatedly rub along the lid margins while eyes are closed. '''3. Antibiotic reduction of lid margin bacteria (at the discretion of your physician):

After lid margin cleaning, spread small amount of prescription antibiotic ophthalmic ointment with finger tip along lid fissure while eyes closed. Use prior to bed time as opposed to in the morning to avoid blurry vision.

The following guide is very common but is more challenging to perform by visually disabled or frail patients as it requires good motor skills and a mirror. Compared to above it does not bear any advantages:

1. Apply hot compresses to both eyes for 5 minutes once to twice per day.

2. After hot compresses, in front of a mirror, use a moist Q-tip soaked in a cup of water with a drop of baby shampoo. Rub along the lid margins while tilting the lid outward with the other hand.

3. In front of mirror, place small drop of antibiotic ophthalmic ointment (e.g. erythromycin) in lower conjunctival sack while pulling lid away from eye with other hand.

Often the above is advised together with mild massage to mechanically empty glands located at the lid margin (Meibomian glands, Zeiss glands, Moll glands).

Depending on the degree of inflammation of the lid margin, a combination of topical antibiotic and steroid drops or ointments can be prescribed to provide instant relief. However, this harbors significant risks such as increased intraocular pressure and posterior subcapsular cataract formation. Since cataract formation is irreversible and even intraocular hypertension might be (harboring the risk of glaucoma with permanent visual loss), both need to be checked for monthly. Steroid-induced cataracts and ocular hypertension can affect all ages.

If acne rosacea coexists, treatment should be focused on this skin disorder as the underlying cause together with the above lid margin hygiene routine. Typically, 100 mg doxycycline by mouth twice per day is prescribed for four to six weeks which can be tapered to 50 mg once daily for several years. Some physicians use a lower starting dose. Patients are instructed to continue use for at least two months before symptoms improve significantly. Contrary to common belief, use of tetracycline-type antibiotics is not primarily to treat bacterial infection but rather to inhibit matrix metalloproteinases resulting in thinning of oil gland secretions and change of the characteristic prominent capillary pattern.

Dermatologists treat blepharitis similarly to seborrheic dermatitis by using safe topical anti-inflammatory medication like sulfacetamide or brief courses of a mild topical steroid. Although anti-fungals like ketoconazole (Nizoral) are commonly prescribed for seborrheic dermatitis, dermatologists and optometrists usually do not prescribe anti-fungals for seborrheic blepharitis.

'''4. Ocular Antihistamines and allergy treatments:

If these conventional treatments for blepharitis do not bring relief, patients should consider allergy testing. Allergic responses to dust mite feces and other allergens can cause lid inflammation, ocular irritation, and dry eyes. Prescription optical antihistamines like Patanol, Optivar, Elestat, and over the counter optical antihistamines like Zaditor are very safe and can bring almost immediate relief to patients whose lid inflammation is caused by allergies.