Eyelid Inflammation (Blepharitis)

Blepharitis (BLEH-fuh-REYE-tis) is a chronic irritation of the eyelids, which causes redness and matting of the eyelids. It has a variety of causes, ranging from allergy and infection to irritation, as well as skin cancers. It is the most common eye disease.

Usually, blepharitis is mainly a nuisance and responds well to treatment.

Blepharitis may be caused by inflammation, bacteria, allergies, tumors, environmental conditions, trauma such as rubbing the lids, tear film irregularities, or it may be related to systemic disease.

• Inflammatory or allergic blepharitis results in increased shedding of skin cells near the eyelids.
• Allergic blepharitis may be caused by irritants in the atmosphere (for example, chemicals at work) or by many medications, either ocular or systemic. In many people, blepharitis is caused by exposure to animals such as a dog or cat.
• The ulcerative form (infectious blepharitis) often results in an infectious yellowish or greenish discharge.
• Tear film abnormalities are characterized by abnormal or decreased tears.
• Blepharitis may be caused by systemic medical conditions or skin cancers of various types.
• Abnormalities of the eyelids include inturning (entropion) or outturning (ectropion).

Blepharitis usually causes symptoms of eye itching, irritation, burning, increased tearing, and the sensation that something "may be in the eye." The complaint that "my eyes feel dry" is common.

With contact-lens wearers, it is often mentioned that "I can't wear my lenses for as long as I did before" and "the lenses irritate me more."

The lids may be red and may have ulcerative, non-healing areas that may actually bleed.

• Vision is usually normal, although a poor tear film often blurs vision, causing varying amounts of fluctuating vision during the day.
• Redness, warmth, and swelling in advanced cases may also be noted.

In allergic blepharitis, the lids may appear dark like raccoon eyes. This is called an "allergic shiner" and is very common in children.

• Flaking and eyelid matting or "gluing" of the lashes are common.
  • In the infectious form, there may be yellow- or green-colored fluid/discharge, which causes sticking of the lids, especially in the morning.
  • With the most common seborrheic form, dry, flaky patches of skin may develop. Dandruff is common on the scalp and the eyebrows.

Secondarily, the cornea may show tiny erosions or peripheral corneal ulcers.

Blepharitis may localize in the skin of the eyelids causing a sty or a chalazion, which, if it does not respond to medical treatment, may require incision (lancing) for drainage.

Increased tear production is common and may be quite bothersome.

Chronic blepharitis may result in damage of varying severity, including redness, tearing, and matting of the lids. This may have a marked negative effect upon vision and therefore upon the eyeglass prescription. An inflammatory nodule of the lids (a sty) may develop. This is treated with antibiotic drops, hot compresses, or incision.

Use of contact lenses or dry eyes may also cause noninfectious blepharitis. Since there are many germs on the eyelids, antibiotic drops may be used in these conditions, as well.

Seek medical attention from your primary-care physician or your ophthalmologist when the irritation is bothersome and not improving with conservative use of warm compresses. It would be unusual to go to an emergency room for management of blepharitis.

Since blepharitis does not affect vision generally, any associated changes in vision (they would probably be unrelated) require immediate evaluation by your ophthalmologist (a medical doctor who specializes in eye care and surgery).

Gradual vision changes that occur over several days should also be evaluated by your ophthalmologist, but these gradual vision changes are usually not an emergency. They are rarely caused by the blepharitis.

In general, call your ophthalmologist if you develop these symptoms:

• eye pain,
• change in vision,
• new or changed symptoms (Medications for blepharitis may cause side effects.),
• symptoms that last for more than two weeks, or
• a sore on the eyelid that persists or increases in size, especially if it is red, bleeding, and not healing.

If you cannot reach your ophthalmologist and you experience any acute (sudden) change in your vision, go to a hospital's emergency department for evaluation (rarely necessary with blepharitis since this is typically not an emergency and usually does not affect vision). Sudden loss of vision is a true medical emergency. This is rarely caused by or related to blepharitis but must be evaluated quickly.

• What is the cause of my symptoms?
• How can I treat my condition now and prevent these symptoms from recurring in the future?
• Will I develop any permanent vision loss from blepharitis? Essentially, this is never the case, except for some unusual causes.

Your ophthalmologist or primary-care physician usually diagnoses this condition after a careful history and an examination of your eyes and eyelids.

The exam usually consists of checking the vision after which the lids are examined, usually using the slit-lamp (microscope) if an ophthalmologist is consulted (the primary-care physician doesn't use a microscope).

Other diseases may affect your eyelids, so some of the questions or the examination may be focused on other parts of your body, as well as any medications, such as chemotherapeutic agents or antidepressants, that you are taking. The work environment, including exposure to any chemicals, may also be explored.

Occasionally cultures are taken -- swabbing the discharge and sending this to the laboratory to look for specific organisms. This is usually reserved for infections that don't respond to the usual medications.

If it is suspected that the blepharitis is related to or caused by a systemic disease, a more complete evaluation by your primary-care physician may be indicated.

In some cases, an allergy evaluation may be required.

Good eyelid care is usually sufficient for treatment. Until this condition is cleared, you should refrain from using eye makeup or wearing contact lenses. Your lenses should be placed in a clean case with clean disinfectant solution. Daily eyelid care may be required after the initial episode has cleared.

• Apply warm moist compresses to your eyelids for 10-20 minutes four times per day to cleanse them and to reduce discomfort. If you want to keep the compresses warm for a longer period of time, you may want to place a small hot water bottle over the compress. Using a clean wash towel for each cleansing is important. Be careful to avoid rubbing or scratching your eyes.
• Using a cotton swab, carefully cleanse the lid margins with a swab moistened with dilute baby shampoo or a baby body wash solution in the morning and at bedtime.
• Artificial tears may also make the eyes feel more comfortable.
• Gentle massage of the lid margins two to three times a day is helpful. Wash off the lids several times a day. Try gently to remove the crusts without damaging the eyelids.
• Do not share eye makeup or eyedrops, since you often touch the lids with the eye dropper and might give your infection to others.

Anytime that there is discharge from the lids, be careful to wash your hands often and not use other people's towels (or allow them to use yours). In most situations, there is minimal or no discharge, and the blepharitis is not contagious, except by direct contact via your hands or the secretions from the eye.

The cornerstone of therapy is good eyelid hygiene.

A doctor may prescribe one of several topical antibiotics (each physician has his or her own preferences) if your ophthalmologist or primary-care physician believes that you have an infectious form of blepharitis. Often, doctors may also prescribe antibiotic-steroid combinations. Occasional blurriness of vision may occur after eyedrops or ointments are placed in your eyes. This should clear up quickly with blinking. Ointments may also be used. However, they may cause blurring of vision.

Never use other people's eyedrops or medications. Occasionally, antibiotic drops or ointments that contain cortisone are used. If any cortisone drops or ointments are used, they should not be used for prolonged periods of time since they might cause glaucoma in susceptible individuals. These medications should never be used without the supervision of an ophthalmologist. Relatively recently, a topical cyclosporine drop has proved its efficacy in some patients. Massage of the lids several times a day may help empty the glands of the lid.

Resistant cases of infectious blepharitis may need a prolonged course of oral antibiotics (in addition to ointments such as tetracyclines or azithromycin).

Sensitivity to the topical or systemic medications may occur. If so, check with the prescribing physician or optometrist.

Recently, there has been interest in using omega-3 fatty acids in pill form for treatment of blepharitis and dry eye.

Allergic blepharitis appears similar to bacterial blepharitis and is treated with steroid (or antibiotic-steroid) eyedrops for a short period of time.

Blepharitis usually responds well to treatment. Your ophthalmologist will monitor your response to therapy on a periodic basis. Usually one visit is sufficient, with additional exams carried out only if it doesn't respond adequately to the treatment.

If dandruff is present, this must be treated with special shampoos.

If blepharitis is caused by an allergy at home or at work, simply avoiding the allergen (for example, a dog or cat) may avoid future problems. Steroid drops, by themselves or in combination with an antibiotic, may be prescribed.

In infants, the cause of the blepharitis may be a blocked tear duct. This is treated with gentle massage of the lids several times a day. In stubborn cases, the block might have to be opened with a special probe.

Long-term eyelid care may be necessary to prevent a recurrence of blepharitis. This may involve a combination of lid scrubs and medications.

If blepharitis is especially persistent and resistant to treatment, additional treatment with systemic medications (as mentioned above) may be necessary. It is important to rule out a malignancy in or near the eyelids.

If a patient who is scheduled to have eye surgery develops blepharitis, the surgery is usually postponed until after the blepharitis is treated.

American Academy of Ophthalmology
655 Beach Street
Box 7424
San Francisco, CA 94120
415-561-8500

American Academy of Ophthalmology