Conditions: Blepharitis

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What is blepharitis?

Blepharitis is a very common inflammatory condition of the eyelid margin (the rim of the eyelid where the eyelashes are located). Bacteria which normally live on our skin are attracted to crusts around the base of the eyelashes and produce chemicals which irritate the eyes causing symptoms of itching, irritation and burning. Special tear glands, called meibomian glands, which are located in the eyelids, become blocked. Since these glands help to prevent the tear film covering the very sensitive cornea (the clear window of the eye) from evaporating too quickly bin between blinks, blepharitis results in:

• Tear film instability resulting in irritation, a foreign body sensation, burning, itching and redness of the eyes (dry eye symptoms)
• Tearing of the eyes due to an overproduction and overflow of tears as a reflex reaction to eye irritation
• Red inflamed eyelid margins (see photograph below)
• Cyst formation in the eyelid (chalazion or meibomian cyst - see photograph below)
• Loss of eyelashes
• Inturning of the eyelid margins (entropion) resulting in painful rubbing of the eyelashes against the cornea
• Corneal ulcer (marginal ulcer or marginal keratitis)

Severe blepharitis

A typical upper lid chalazion (meibomian cyst) in a patient with mild blepharitis. The patient also has a plugged meibomian gland duct in the central aspect of the lower eyelid which will result in another chalazion if untreated).

How do I know if I have blepharitis?

The edges (rims) of the eyelids are red and the eyelashes are stuck together by tiny crusts. The whites of the eyes are often red and sore. In the mornings the eyelids stick together, sometimes with a yellow discharge.

These changes cause the eyes to be sore and irritable, with a gritty foreign body feeling. Watering due to the reflex production of excess tears is common.

What causes blepharitis?

Blepharitis is more common in people with certain skin disorders:

Seborrhoeic dermatitis – a common scaly skin condition. This typically causes dandruff and sometimes a rash on the cheeks and forehead.

Rosacea – a skin condition that typically affects the cheeks and nose. Symptoms include facial flushing, facial redness, and red spots.

Eczema (atopic dermatitis) – an itchy inflammation of the skin which tends to flare-up from time to time. It can be associated with allergies.

There are 2 main types of blepharitis:

Anterior blepharitis

Tiny dandruff-like flakes form along the bases of the eyelashes. Bacteria invade the flakes and cause anterior blepharitis in some people (see photograph above showing severe anterior blepharitis). Seborrheoic dermatitis, which typically causes dandruff, can also cause these flakes to build up along the eyelid margin.

Posterior blepharitis:

A row of special glands in the upper and lower eyelids (the meibomian glands) secrete an oily substance that coats the tear film and maintains its stability over the cornea in between blinks. In some people the ducts of the meibomian glands become blocked. This results in meibomiitis.

Meibomitis results in:

1. Tear film instability and dry eye: the oily secretions can no longer coat the tear film effectively which evaporates too quickly leaving the eye feeling irritable and sore

2. A frothy discharge on the eyelid margins

3. Clogging up of the meibomian gland ducts on the eyelid margin resulting in the formation of a plug (see photograph above)

4. The formation of eyelid cysts (chalazia or meibomian cysts) as the blocked meibomian gland swells and bursts its capsule resulting in a red swollen eyelid (see photograph abov

 

Is it serious?

No, it is not serious, and only very rarely causes any permanent damage to the eyes. However, blepharitis is a very persistent problem. (Blepharitis which is confined to the eyelid(s) on one side only should however be viewed with suspicion as very rare tumours can mimic blepharitis and lead to misdiagnosis).

Can it be treated?

Yes, though treatment usually can only control the problem and cannot eradicate it altogether. Go to the following for further information about treatment options: http://www.faceandeyeshop.co.uk/product_list.cfm?id=19

What is the treatment?

Eyelid hygiene is the mainstay of treatment and should be performed twice daily for the first 2-3 weeks and then at least once daily indefinitely to keep the inflammation under control.

There are 3 steps needed for effective lid hygiene:

1. Heat application

2. Massage

3. Cleaning

Heat application:

Heat applied to the eyelids for 5 minutes:

• Softens the skin and any crusts attached to the eyelids
• Helps to unplug the ducts of the meibomian glands
• The traditional method is to apply a hot moist flannel or cotton pad to the closed eyelids. This is somewhat tedious because the flannel or cotton wool cool quickly and need to be repeatedly heated up in warm water
• The EyeBag™ is a much more convenient and effective method of heat application because it supplies sustained warmth for 5-10minutes (to purchase on-line go to http://www.faceandeyeshop.co.uk)

 

Massage:

• Massage the eyelids with your forefinger immediately after applying the warmth.
• Massaging helps to push out the oily fluid from the meibomian glands which helps to stabilise the tear film on the surface of the eye.
• Massage the upper eyelid and the lower eyelid gently towards the eye. This action should be repeated 5 to 10 times over about 30 seconds immediately following the warming.
• Massaging should neither to be too gentle nor too firm. It should be relatively comfortable and you should not press hard enough to actually hurt your eyeball under the closed eyelids.

 

Cleaning:

• After heat application and massage, clean the eyelids.
• Blephaclean® wipes twice daily for 1 or 2 weeks are an excellent way to achieve rapid control of blepharitis. (These wipes are particularly useful in removing eye make-up, avoiding irritation/allergy associated with other eye make-up removers). Blephasol® solution on a cotton bud once daily can then be used as daily maintenance to keep the eyelid margins clean.
  You can order these from: http://www.faceandeyeshop.co.uk/product_detail.cfm?id=2

 

Antibiotic ointment:

• In severe blepharitis a topical antibiotic (e.g Chloramphenicol ointment) can be applied to the lid margins after performing lid hygiene for a period of 2 weeks. This can reduce the bacteria contributing to eyelid margin inflammation and make it easier to control blepharitis using the treatment described above.
• Ointments/drops containing steroids should not be used unless prescribed by an ophthalmologist.

 

Oral antibiotics:

• Occasionally if posterior blepharitis cannot be controlled with local treatment as described above it is worth considering a 6-12 weeks course of oral doxycycline (typically 100mg taken orally once daily) as this can reduce the inflammation associated with blepharitis. N.B. This cannot be used during pregnancy.

 

Is that all I have to do?

Since blepharitis causes tears to be abnormal, artificial tears can give relief from irritation, even when your eyes are watering (eyes can water as a reflex reaction to a basic dry eye problem or tear film abnormality). These should be used at least 4 times a day at least to prevent symptoms rather than to just relieve symptoms. There is a large variety of artificial tear preparations to choose from. It is essential to use preservative free drops.

Preservative free: Hyabak drops, Hylotears, Hylotears Forte, Systane drops preservative free, Viscotears preservative free, Celluvisc or Liquifilm tears preservative free. These can be ordered from: www.faceandeyeshop.co.uk (eye products).

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Dry Eye  

Dry eye is a very common problem which is most often treated with artificial tears. Alternative options include the use of punctal plugs which are placed in the commencement of the tear drainage system in the lower eyelids (the inferior puncta). These are reversible. They are initially used as a trial to ensure that a patient with a dry eye does not develop secondary overflow tearing. If this happens, the plugs are removed. A permanent solution is the application of cautery to the inferior puncta.

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Dark Circles  

Tear Trough  Restylane Injections

This new non-surgical treatment is appropriate for some patients with lower eyelid dark circles/dark hollows (also referred to as “tear troughs”). In the lower eyelid a weakening of the orbital septum, and in the cheek area (the “mid-face”) a loss of soft tissue volume, tend to accentuate the appearance of the lower bony orbital margin which lies between the lower eyelid and the cheek. This also leads to the appearance of lower eyelid fat pockets and together these can lead to a “tear trough” depression, or dark shadow or hollow.

Lower lid dark circle (tear trough)

Not all patients who complain of lower eyelid dark circles or dark hollows are suitable for surgical improvement, usually in the form of a lower eyelid blepharoplasty or eye bag removal. The use of Restylane or Juvéderm injections offers some patients a less invasive alternative treatment for their problem as shown in example 1. Some patients also benefit from Restylane Sub-Q or Juvéderm Voluma injections which help to restore a youthful shape to the face by filling the inner and outer part of the upper cheeks as shown in example 2. This patient has also undergone anti-wrinkle botulinum toxin injections to her forehead with an improvement in forehead lines and brow shape.

Although the use of Restylane and Juvéderm as soft tissue fillers in other areas of the face is very well established and associated with high patient satisfaction, their use for the management of “tear troughs” and, with Restylane Sub-Q or Juvéderm Voluma, the management of a loss of soft tissue volume in the mid-face is proving to be a very good new application for many patients. The effects of the injections last approximately 6-12 months before repeat injections are required. The treatment is undertaken as an outpatient procedure that offers immediate cosmetic results, a reduced risk of complications that are associated with surgery and a very short recovery period. Restylane Sub-Q, or Juvéderm Voluma can also be injected into the cheeks. Restylane can also be injected as a trial treatment without removing the option of surgery at a later stage. . It can also be used for patients who have previously undergone cosmetic eyelid surgery and have some residual hollowing of the lower eyelids.

The treatment is associated with mild discomfort and a short "down time". The injections also contain lidocaine, a local anaesthetic, which helps to minimise any discomfort. Bruising and swelling usually take a few days to subside. Occasional contour irregularities can occur following the injections. These are managed with massage after applying Auriderm cream - (http://www.faceandeyeshop.co.uk/product_list.cfm?id=25). If a patient is dissatisfied with the results, the Restylane or Juvéderm can be dissolved with the use of a small injection of Hyalase (an enzyme commonly used in local anaesthetic solutions given around the eye in patients undergoing cataract surgery). In order to minimize the risk of bruising it is advisable to discontinue the use of Aspirin, Anadin or any anti-inflammatory medicines e.g. Indomethacin, Ibuprofen, Diclofenac, Voltarol, for 2 weeks before treatment provided it is medically safe to do so (please discuss this with your GP or physician if in doubt about this). It is quite alright to take Paracetamol. Excessive bruising can lead to staining of the Restylane gel in the lower eyelids and a blue discolouration of the skin. This occurs rarely but is the reason why it is important to avoid medications which predispose to bruising.

This treatment has proved popular with both men and women of ages ranging from 21 to 55 years of age. A consultation is important to ascertain a patient’s suitability for this treatment. In the hands of an experienced oculoplastic surgeon, the risks and potential complications are very small but these must be considered carefully following a discussion at a consultation before proceeding with the treatment.

It is always preferable not to plan the treatment on the same day as the consultation but to have time to reflect on the discussions first and return for the treatment on a separate occasion.

Appearance of lower lid dark circles causing a very tired appearance		Appearance 2 weeks following Tear Trough Restylane injections

 

Appearance of lower lid dark circles causing a very tired appearance		Appearance 2 weeks following Tear Trough Restylane injections

 

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