Blepharitis And Autoimmune Diseases

Blepharitis, unlike autoimmune diseases, is a common condition that often has a good prognosis and can affect every age group.¹ It is, after all, one of the most diagnosed conditions in ophthalmic practice. This ocular condition is characterised by eye irritation and discomfort² and is known to be associated with several systemic diseases.¹ However, out of the 100 known autoimmune diseases,⁶ blepharitis is not a cause of one — instead, blepharitis is a complication of a symptom manifested in an autoimmune disease. Also, sometimes blepharitis acts like a package deal that comes with an autoimmune disease, which acts as a complication of other autoimmune diseases.

Understanding blepharitis and autoimmune disease

What is blepharitis?

It is simply an eyelid margin inflammation,¹ often characterised by pain,³ irritation, and discomfort.² Blepharitis could be acute or chronic — however, it mostly presents as a chronic condition, which accompanies recurring symptoms that vary and can even affect both the eyes.⁴

Causes and types of blepharitis 

The causes of blepharitis make it chronic or acute.⁴ The acute form of blepharitis could be ulcerative or non-ulcerative.⁴ Although ulcerative blepharitis is commonly caused by staphylococcal bacteria and viruses like Herpes simplex and Varicella zoster.⁴ Non-ulcerative blepharitis, on the other hand, is caused by an allergic reaction, which could be atrophic or seasonal.⁴ Some items that could potentially cause allergic reactions include: 

• Eye medications
• Cosmetics
• Contact lens solutions 

 Based on the location of the infection, chronic blepharitis can be further classified into anterior, posterior, or mixed.³

• Anterior blepharitis: It occurs at the bottom of the eyelashes and follicles.³ It is commonly caused by infectious agents like bacteria, viruses or parasites such as Staphylococcus, Molluscum contagiosum, and phthiriasis respectively.¹ It can also be caused by seborrhoeic dermatitis¹ 
• Posterior blepharitis: It involves the meibomian gland and is often metabolic.¹ Posterior blepharitis is a result of meibomian gland dysfunction, leading to reduced meibom secretion³

Other causes of blepharitis include:³

• Poor eye hygiene
• Eye mites

Symptoms of blepharitis 

Common symptoms of blepharitis are burning sensations, foreign body sensations, ocular irritation, misdirected eyes, and loss of eyelashes.^2,3 However, some symptoms are specific to the type of blepharitis:³

 Anterior blepharitis:

• Eyelid ulceration
• Crusting around the lashes
• Blurry vision
• Light sensitivity
• Sticky eyelids in the morning 

Posterior blepharitis: 

• Foamy tears
• Chalazia
• Red, swollen eyelids, and scarring 
• Corneal neovascularization 
• Corneal ulceration 
• Marginal infiltration and pannus

 Symptoms of blepharitis usually worsen in the morning due to the constant contact between the inflamed lids and the ocular surface during sleep.¹

Overview of autoimmune diseases

What are autoimmune diseases?

The immune system is our defence tower, housing many soldiers whose duty is to protect us against the common enemy: foreign bodies and pathogens. When the immune system deviates from this common enemy and starts seeing the body as its enemy, it proceeds to attack. That’s how an autoimmune disease is initiated. 

It is a clinical collection of different symptoms caused by the activation of either T or B cells or even both in the absence of a present infection or any plausible cause.⁷ It occurs because of the immune system's overreactivity⁷ and when it cannot differentiate between self and foreign bodies.⁵ In addition, autoimmune diseases are divided into two types clinically. It can either be systemic like lupus erythematosus or organ-specific like type 1 diabetic mellitus.⁷

What causes autoimmune diseases?

Most causes of autoimmune diseases are unknownL,⁷ as different autoimmune diseases appear in several ways with varying onset.⁵ They often have complicated origins due to factors like genetics, hormones, and environment.⁵

• Genetics: It places an individual at risk of autoimmune diseases high up the scale.⁷ Factors like familial clustering and being an identical twin can also increase the risk of autoimmune diseases⁷
• Environment: Before an autoimmune disease presents itself in an individual who is at risk, there has to be an environmental exposure or at least a change in the internal environment to stimulate overreactivity⁷.
• Infectious agents: Infection with microbial antigens can stimulate overreactivity, as they cause inflammation, release of stored antigens and autoimmunity⁷
• Non-infectious agents: Drugs such as procainamide (to treat irregular heart rates) can alter the immune stores and antibiotics such as penicillin and cephalosporins can act as haptens and make auto antigens immunogenic.⁷ Women are at higher risk than men, especially in the case of lupus erythematosus, where oestrogen worsens it⁷

What are Some Examples of Autoimmune Diseases?

The following is a list of some autoimmune diseases:^5,6

• Type 1 Diabetes 
• Crohn disease 
• Ankylosing spondylitis
• Multiple sclerosis
• Coeliac disease 
• Rheumatoid arthritis
• Systematic lupus erythematosus
• Sjogren syndrome 
• Graves disease 
• Ulcerative colitis
• Addison disease 

Association between blepharitis and autoimmune diseases

While blepharitis does not directly cause autoimmune diseases, it manifests as a complication of a symptom. One condition in particular closely linked to blepharitis is Sjögren syndrome. It is a chronic inflammatory disease of the exocrine glands in our body causing functional impairment, especially, salivary and lacrimal glands.⁸

Sjögren syndrome leads to two classic symptoms, namely, xerophthalmia and xerostomia.⁸ While xerostomia affects the oral cavity, xerophthalmia affects the ocular system. A significant complication of xerophthalmia is blepharitis⁸ Although it occurs mostly as posterior blepharitis, it rarely demonstrates anterior blepharitis.¹⁰ In this case, blepharitis could also be caused by a bacterial infection (staphylococcus), eyelid dermatitis due to frequent eye rubbing,⁸ or an imbalance between androgen and following menopause.¹⁰

Sjögren syndrome is classified as primary or secondary, i.e. it either presents its own symptoms or is in association with other autoimmune diseases⁸. In association with other diseases, Sjögren syndrome is commonly presented as a complication in rheumatoid arthritis and systemic lupus erythematosus ⁸.

How do I treat blepharitis in autoimmune diseases?

Blepharitis is regarded as problematic in patients with Sjögren’s syndrome because of the irritation and evaporative dryness it causes¹⁰. However, blepharitis occurs in any of the previously mentioned autoimmune diseases can be treated as follows ^{8 9}:

• Topical erythromycin 
• Warm compress 
• Lid scrubs using baby shampoo 
• Application of artificial tears 3 to 4 times daily
• Placing moist cotton balls over the eyes while sleeping
• Avoid rubbing the eyes

Lid scrubs are particularly helpful as they remove eyelid debris that can carry bacteria, which worsens the condition⁹. It also helps to reduce tear evaporation⁹. 

FAQ’s

Which systemic diseases cause blepharitis?

Some systemic diseases that cause blepharitis include:¹

• Rosacea
• Seborrhoeic dermatitis 
• Chalazion 
• Conjunctivitis 
• Keratitis

Why am I suddenly getting blepharitis?

The sudden causes of blepharitis could be: 

• Bacterial build-up
• Clogged meibomian glands
• Lack of proper eye hygiene 

Can autoimmune diseases be cured?

No, They can't be cured, only their symptoms can be managed.

Which autoimmune diseases cause eye infections?

Eye infections like conjunctivitis, episcleritis, and scleritis are associated with autoimmune conditions like rheumatoid arthritis and systemic lupus erythematosus.¹¹

How do I stop blepharitis from coming back?

Remember, blepharitis could be chronic — it can reoccur several times. However, you could practise good eye hygiene to help prevent rapid recurrence KEY WORDS Needed

Summary

Blepharitis is an inflammation of the eyelid that could be acute or chronic.⁴ An acute blepharitis could be ulcerative or non-ulcerative, while chronic blepharitis can be location-specific - anterior and posterior blepharitis with specific symptoms despite eye irritation and discomfort. Additionally, a strong association is commonly found between posterior and anterior blepharitis and autoimmune diseases such as Sjögren syndrome, rheumatoid arthritis, and systemic lupus erythematosus.