Overview

Blepharitis is a common condition, affecting all age groups, which causes inflammation of the eyelids. Blepharitis can be caused by infection or may be associated with skin conditions, such as seborrheic dermatitis, rosacea, and psoriasis.¹ The symptoms of blepharitis often fluctuate and are generally treated at home with measures that optimise good eyelid hygiene. In some cases, more serious complications require referral to a specialist and medical treatment. 

Definition of blepharitis

The word blepharitis derives from the Greek word for eyelid (Blephera) while ‘itis’ refers to inflammation. Although the cause of blepharitis is not fully known, it is often linked to poor functioning of the oil-producing glands on the eyelids known as the meibomian glands. Abnormal secretions from the eyelids, bacteria, Demodex mites and abnormalities of the tear film may all contribute to the condition. 

Blepharitis frequently involves the meibomian glands. If it affects the skin and lashes, it is usually due to seborrheic dermatitis or staphylococcal infection. Blepharitis, however, is not contagious. 

How common is blepharitis? 

Blepharitis symptoms are very common and studies suggest that younger people report symptoms more frequently compared to an older population.² Ophthalmologists and optometrists report that around 4 in 10 patients in their clinical practice present with blepharitis and it is widely recognised that meibomian gland dysfunction is the most common cause. 

Causes of blepharitis

Bacterial infection

Blepharitis is often caused by bacteria or mites. Bacteria is normally present on the skin but when there is an excess of bacteria, it can lead to irritation and clogging of the glands. Staphylococcus aureus is the most commonly identified bacteria in blepharitis.³ 

Seborrheic dermatitis

Dandruff (linked to seborrheoic dermatitis) causes flaky patches of skin on your scalp, which are prone to fall into the eyes causing irritation and blockage. 

Rosacea

Rosacea is a common chronic skin condition causing redness of the face, which can be associated with blepharitis. It has an appearance similar to acne and is most noticeable around the cheeks. It is especially common in Northern European populations and can occur at any age, but is commonly seen between 30 to 50 years of age.⁴ 

Psoriasis

Psoriasis is a long-term, autoimmune skin condition, often running in families, which can be linked to arthritis and blepharitis.⁵

Dysfunction of the meibomian glands

The meibomian glands are found at the back of the eyelids. These glands provide lubrication to the tear film to help maintain a healthy ocular surface and prevent dryness. When the glands block, this is known as meibomian gland dysfunction which contributes to symptoms of dry eye. 

Other contributing factors

• Poor eyelid hygiene
• Use of contact lenses
• Hormonal changes
• Allergies
• Environmental factors, such as air pollution and exposure to dust 

What are the different types of blepharitis?

There are two main types of blepharitis, however, you may have a combination of both. 

Anterior blepharitis 

Anterior blepharitis affects the exterior eyelid, at the base of your eyelashes. It usually happens as a result of bacteria on your skin or dandruff from your scalp or eyebrows. Allergies or Demodex mites may also, less frequently, cause anterior blepharitis. 

Posterior blepharitis

Posterior blepharitis affects the inner eyelid. This type of blepharitis occurs when the oil glands in your eyelids get blocked, usually due to meibomian gland dysfunction.⁶

Mixed-type blepharitis

When you have both anterior and posterior blepharitis, this is known as mixed-type blepharitis. 

Symptoms of blepharitis

The main symptoms of blepharitis include:

• Sore eyelids
• Watering or itchy eyes 
• Gritty feeling in the eyes
• Flakes of skin or crustiness around the roots of the eyelashes
• Eyelids sticking together in the morning 
• Red eye appearance⁷ 
• In more advanced stages, blepharitis can cause blurry vision

Diagnosis of blepharitis

Blepharitis can be diagnosed by your GP or an ophthalmologist who will take a history of your symptoms and examine your eyes, eyelids and eyelashes. Your doctor may use a bright light or magnifying tool to examine your lid margins and meibomian gland openings. They may check the quantity or quality of your tears. A swab of the eyelid may also be taken to check for bacteria. Examination of your eyes by a trained professional can rule out similar causes of red eye, such as conjunctivitis or keratitis. 

How do you treat blepharitis?

In most cases, blepharitis can be treated at home. You can follow these steps: 

• Clean your eyelids twice daily initially and then at least once a day as symptoms improve
• Keep cleaning your eyes consistently, even if your symptoms clear up
• Regularly use a warm, clean damp cloth or an ‘eye-bag’ that can be heated in the microwave and placed over your eyes 
• Do not wear contact lenses while you have symptoms
• Avoid rubbing your eyes
• Avoid using irritant make-up, such as mascara and eyeliner 

Medical treatment

The foundation of blepharitis treatment is eyelid hygiene, which must be continued long-term. However, you may need to seek medical advice if your symptoms persist or worsen. Your doctor or optometrist can diagnose blepharitis by examining your eye and eyelashes. You may be prescribed eye drops, antibiotic cream or oral antibiotics if necessary. Topical antibiotics can be used to reduce the bacterial load and topical steroid preparations may be helpful if the eyelids are very inflamed.⁸ 

Aims of blepharitis treatment

The main goals of blepharitis treatment are relieving the symptoms, preventing repeated flare-ups and reducing the risk of complications. 

Complications of blepharitis

There are a number of potential complications associated with blepharitis.

• Chalazion and Styes: Chalazia and hordeola (styes) are localised swellings of the eyelid. A chalazion is caused by persistent meibomian gland blockage, whereas a stye is usually driven by infection. Both conditions initially cause eyelid redness and swelling. Treatment with warm compresses and good eyelid hygiene can be effective
• Conjunctivitis: Conjunctivitis is inflammation of the conjunctiva, a transparent membrane that lines the eyelid and eyeball. The redness occurs due to small blood vessels in the conjunctiva becoming swollen and irritated. It usually resolves on its own, although treatment may be necessary in some cases
• Keratitis: Keratitis is inflammation of the cornea which can be associated with an infection or minor injury. Keratitis can lead to serious complications that permanently damage your vision, if left untreated
• Eyelash issues: Blepharitis can cause your eyelashes to grow abnormally, lose colour, or fall out
• Eyelid skin problems: Long-term blepharitis can cause scarring of your eyelids. The eyelid edges might begin to turn inward or outward
• Excess tearing or dry eyes: Blepharitis can affect the tear film and irritate your eyes, causing dry eyes or excessive tearing

Summary

Blepharitis is a common condition which causes discomfort in the eye. It can be caused by infection or dysfunction of the meibomian glands. Blepharitis is a long-term condition and unfortunately, there is no cure. However, maintaining good eye hygiene can help treat the symptoms. In some cases, for example, if complications materialise, medical intervention may be required. More research is needed to understand why blepharitis develops to enable the development of more effective treatments in the future.