Introduction

Blepharitis and dry eye are two commonly occurring eye conditions that cause discomfort and irritation. They are two separate conditions but have many overlapping features that can make them difficult to tell apart. As these conditions may influence each other, they often occur at the same time., Blepharitis is a chronic inflammation of the eyelids while dry eye occurs when there are not enough, or poor quality, tears being produced.^1,2 This article will cover both conditions, including the causes, symptoms, diagnosis, and treatment options. 

What is blepharitis?

Blepharitis is a common eye condition that is characterised by inflamed eyelids, especially seen towards the base of the eyelashes.¹ It can be caused by various factors including bacterial infections, skin conditions like seborrheic dermatitis or rosacea, and allergies.¹ The condition is chronic and can be uncomfortable, but it is not contagious and can be managed with steps to ensure good eyelid hygiene. 

Symptoms of blepharitis

Common symptoms include:³

• Red, swollen eyelids
• Burning or stinging sensation in the eyes
• Crusty eyelashes
• Eyelids sticking together when you wake up in the morning
• A gritty feeling, as if you feel there is something in the eye

More severe symptoms of blepharitis can result in:^1,3

• Styes - a red, painful bump on the eyelid
• Chalazia (a type of eyelid cyst) - a hard, painless lump
• Chronic dry eye

If you have symptoms of blepharitis, you should avoid wearing contact lenses or eye makeup, such as mascara or eyeliner, which can cause irritation. 

Diagnosis of blepharitis

Blepharitis can be diagnosed by an eye care specialist e.g. optician, who will examine your eyes using a magnifying instrument (known as a slit lamp) to look for inflammation, redness, and crusts around your eyelids.⁴ This tool can also help visualise any blockages of your oil glands, which are common in individuals with blepharitis. In some cases, the specialist may use a swab to collect a sample of the oil or crust from your eyelid.⁴ This can then be sent to the laboratory to look for growth of bacteria or evidence of allergies. 

Treatment of blepharitis

The main treatment for blepharitis is cleaning the eyelids frequently to remove crusts and any debris that has formed.^3,4 This can be achieved using a warm compress, gently massaging the eyelids and cleaning away debris, for example, with cotton buds or eyelid wipes.

In more severe cases your healthcare professional may prescribe you medications, such as antibiotics or steroid eye drops, which can help control inflammation in blepharitis.^3,4 

What are dry eyes?

Dry eyes is a common condition that occurs when your tears are not able to provide adequate lubrication for your eyes.² This can either happen when you don't produce enough tears or if your tear quality is poor.⁵ 

Conditions like Sjögren's syndrome and some medications can reduce the production of tears.⁵ People aged over 50 years are more at risk of developing dry eyes. Blinking less frequently (which is common with increased screen time), eyelid problems, and exposure to wind, smoke, or dry air can increase the evaporation of tears.⁵ External factors, such as living in a dry climate, can also make dry eye symptoms worse by causing tears to evaporate more quickly.⁵

Symptoms of dry eyes^2,5

• Burning sensation in the eyes
• Feeling of grittiness inside the eye
• Redness and general irritation around the eye 
• Light sensitivity
• Watery eyes

Diagnosing dry eye

Dry eye can be diagnosed by professionals using simple tests. Commonly, the Schirmer Test is used to measure your tear production.⁶ A small piece of paper is placed under your lower eyelid to assess the level of moisture with tears over a set time period. The Tear Breakup Time Test checks how long it takes for tears to start breaking up on the surface of your eye. For this test, a dye is applied to your eye and the time it takes for dry spots to appear is measured. There is also the Fluorescein Staining Test that similarly uses a dye to highlight any damage on the surface of your eye, thus helping to identify areas where your tear film is inadequate. These tests can help determine the severity of your dry eye.

Treatment for dry eye

There are several different ways to help manage dry eye.^5,6 In the first instance, you can use artificial tears or eye drops that help add moisture to your eyes. These can be bought over-the-counter at a pharmacy. Ideally, you should use preservative-free eye drops to reduce the chance of irritation. If you have more severe symptoms, a healthcare professional might prescribe you a prescription eye-drop medication to help reduce inflammation and produce more tears.^5,6 You may also be prescribed steroid eye drops for a short period of time to temporarily control inflammation. Occasionally, oral medication like tetracyclines (a group of antibiotics) are prescribed which may improve the function of the oil glands in your eyelids.^5,6

There are several other treatments and devices that can be used to help manage dry eyes. One such device is LipiFlow, a new mechanical system that uses a combination of heat and pressure to clear blocked oil glands in your eyelids.⁷ Another treatment option is scleral lenses, which are contact lenses that help keep your eyes moist. If you have severe dry eyes, you might be recommended punctal plugs: tiny devices that are placed into your tear ducts to prevent your tears from draining as quickly. 

How are blepharitis and dry eye related?

Blepharitis can lead to dry eye because the inflammation from blepharitis affects the tear glands.⁸ When your eyelids are inflamed, it disrupts the normal function of the glands that produce tears, especially the oil-secreting meibomian glands essential for a healthy tear film. Inflammation can block these glands, reducing the quality of the tear film and therefore lead to dry eye.^8,9

On the flip side, having dry eyes can aggravate blepharitis. When your eyes aren't well-lubricated, they can become irritated and uncomfortable very easily. This lack of moisture can lead to further inflammation of the eyelids, which heightens blepharitis symptoms. The irritation and inflammation create a vicious cycle where dry eye and blepharitis make each other worse.^8,9 Since blepharitis and dry eye share several symptoms, it can be difficult to tell them apart. They both cause redness, irritation and light sensitivity.While blepharitis often causes itchiness and a crust or flakiness at the bottom of the eyelashes, dry eye can feel like having an uncomfortable grit inside your eyes. 

Since it is possible to have both blepharitis and dry eye, you may need to treat both conditions at the same time. It is important to ensure you maintain a routine for good eyelid hygiene, including gently massaging the eyelids, to keep blockages in the oil glands as clear as possible.^8,10 Using warm compresses helps to loosen any crusts that have formed and improves the oil flow, which in turn reduces inflammation. Over-the-counter artificial tears can help with dry eye symptoms by adding extra lubrication and reducing irritation.^8,10 Depending on the severity of your symptoms, your healthcare professional may prescribe you medication, such as antibiotic ointments for blepharitis or anti-inflammatory eye drops for dry eye. 

There are several lifestyle changes that you can make to support medical treatment. This includes avoiding wind, smoke and dry air where possible, and adding a humidifier into your sleep and living space.^8,10 Taking Omega-3 supplements may help improve the quality of your tear film and reduce inflammation.^8,10 Staying well-hydrated, eating a balanced diet, and taking vitamin supplements can help support your overall eye health.

Summary

Blepharitis is chronic inflammation of the eyelids and dry eye is a condition where there is inadequate tear production to keep the eyes properly lubricated.  Blepharitis and dry eye can be uncomfortable and the conditions interact and aggravate each other. They can be managed in the first instance by maintaining good eyelid hygiene and using over-the-counter lubricating eye drops. If you suspect you have blepharitis or dry eye, or else your symptoms are not controlled with these conditions, reach out to a healthcare professional for further advice.