What is blepharitis?

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Blepharitis is a term used to describe inflammation or irritation of the eyelids.

The normal eyelid contains glands that secrete a thin and oily fluid, which serves to coat the tears, allowing them to spread evenly across the eye and preventing them from evaporating too quickly.  In patients with Blepharitis, the secretions from these glands often become thickened and plug the openings of the glands.  Once secretions stagnate, the fatty acids in the oils begin to break down into by-products that are irritating to the eyelids and the surface of the eye.  Eyelids then become red and inflamed.  Many patients experience burning, itching, dry eye and foreign body sensation related to this irritation.  The irritated eye then secretes more mucous and protein which often build up on the eyelid and lashes in the form of crusting which is present especially upon awakening the morning.  This crusty material provides a good surface on which bacteria may grow.  The bacteria then secrete irritating substances that further irritate the eye and can damage the glands of the eyelids.

Blepharitis, then, begins as a relatively mild dysfunction of the glands in the eyelids and then progresses through a vicious cycle of inflammation, dry secretions, bacterial infection and possible damage to the glands in the eyelids.  If allowed to continue, the condition may become progressively worse, leading to chronic eyelid inflammation, irritation, and decreased vision.

The severity of Blepharitis varies considerably from individual to individual.  In some cases, it is merely an annoyance; although in others it may cause incapacitating discomfort and lead to sight-threatening complications.

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Blepharitis Treatment Strategy

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The goal and treatment of Blepharitis is interruption of the vicious cycle and normalization of the glandular secretion of the eyelids.  Drugs which may lose their effect after a short period of time (antibiotics) or which may be associated with complications from long-term use (steroids) should be used only for short periods of time.  Oral Tetracycline dosage is initially high and then slowly reduced with time.  Lid scrubs and artificial tears are the mainstays of long term therapy.  They have few complications and can usually maintain good control of Blepharitis once all medications have been withdrawn.  The rate and timing of medication changes will vary from patient to patient and will be determined by response to medication and appearance of the eye on following examinations.

It is very important to remember that Blepharitis is a chronic disease.  Most patients with Blepharitis have had it for many years before they seek care.  The disease is slow in evolving and is, therefore, slow to respond to treatment.  Many patients become discouraged when they do not notice improvement after using medications as prescribed for one to two weeks.  Please realize that several weeks or even months of treatment may be required before any improvement occurs.  Medication should not be stopped just because they don't seem to be doing any good.

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Blepharitis Treatments

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All treatments attempt to interrupt the vicious cycle and allow the eyelid glands to function more normally.

Lid Hygiene

The easiest way to break the vicious cycle of blepharitis is to keep the lid margins as clean as possible.  Reducing the build-up of material on the eyelids and lashes will discourage the growth of bacteria and help to restore the normal functioning of the glands.  Warm soaks to the eyelids twice a day are effective in thinning the secretions and normalizing the flow.  A washcloth, soaked in water as hot as you can tolerate, should be placed over both eyes and left in place for a period of five to ten minutes the water must be changed periodically to ensure that it stays warm.  After this ten-minute period, wrap the washcloth around your fingertip and gently massage your eyelids, both the lower and upper, applying gentle pressure to the eye.  This will tend to remove some of the secretions present in the glands.  The next step is to use a commercial eyelid cleanser.  There are several brands available.  Ocusoft, Eyescrub and Ocucleanse are all comparable.  Not all of these products are available in all drugstores.  Some are available on a premoistened gauze pad, while others require the use of a cotton-tipped applicator or Q-tip which should be moistened in the cleansing solution.  The area of the eyelid where the eyelashes join the eyelid should be cleaned thoroughly, both the upper and lower eyelids.  The cleansing solution will not harm your eye if it was to get into your eye, although care should be taken to avoid this.

Tetracycline

Tetracycline is an antibiotic that has been available for many years and is used in the treatment of a wide variety of infections.  It is commonly used in the treatment of Blepharitis, not so much for its antibiotic quality, but for another beneficial side effect, which is to assist in normalizing the character of the glandular secretions.  Therefore, Tetracycline works by changing the secretions in the glands and by also killing bacteria.

There are a number of possible side effects with Tetracycline.  The most common are nausea and sensitivity to sunlight.  Tetracycline must be taken on an empty stomach to be effective and you should avoid using dairy products within one hour of taking Tetracycline.  Any one taking Tetracycline should take care to use sunscreen when exposed to the sun for prolonged periods of time.

There are different types of Tetracycline available, and each patient may respond differently to each medication.  It is important, therefore, for patients who think they are experiencing problems from Tetracycline to contact the office immediately and discuss the problem.  Often a closely related medication can be substituted to eliminate the side effects.

Artificial Tears

Much of the ocular discomfort and visual loss related to Blepharitis results from irritants and toxins secreted by the bacteria present on the eyelids and by break-down products of the oils in the glandular secretions.  Regular rinsing off the ocular surface with artificial tears can minimize the harmful effects of these toxins.  There are a number of artificial tear products available on the market and they fall into two basic categories.

Preserved Artificial Tears

Preserved artificial tears contain chemicals that prevent bacteria from growing within the bottle.  Preservatives are advantageous in that they allow larger quantities of artificial tears to be packaged and allow a bottle of tears to last longer.  A problem occurs, however, when these artificial tears are used more frequently than approximately four times a day.  The preservatives present in the tears can cause irritation and damage to the eye when used frequently.

Unpreserved Artificial Tears

Several companies pack the same artificial tears in individual small droppers intended for use for less than one day.  Theseartificial tears contain no preservatives and, therefore, the tears may be used as frequently as desired throughout the day without any preservative related complications.  One must take care, however, when using unpreserved artificial tears to ensure that the container remains clean and uncontaminated because bacteria when gain entrance into the dropper may grow freely and may infect the eye when instilled.

Topical Antibiotics

Topical antibiotics of drops and ointments are often used in the treatment of Blepharitis.  They act by killing the bacteria present on the eyelids.  Unfortunately, bacteria may quickly become resistant to antibiotics to which they are exposed for long periods of time.  For this reason, it is advisable for patients with Blepharitis to use topical antibiotics for only short periods of time (approximately two weeks).

Steroids

Steroids are medications which are used to reduce inflammation, redness, and irritation caused by the secretions of bacteria and breakdown products of the fatty acids in the glandular secretions.  Reducing secretions provides a better opportunity for the glands to recover without permanent damage.  Steroids may also reduce the amount of crusting and debris building up on the eyelashes making it difficult for bacteria to grow.

Unfortunately, steroids may have significant complications.  The most common of these is the formation of cataracts and glaucoma when they are used for long periods of time.  Like antibiotics, steroids are indicated often only for short periods of time in the treatment of Blepharitis.

Specific Instructions

Now that you understand something about Blepharitis and its treatment, you should understand how the following medication schedule is designed to work for you.  Please follow these instructions carefully and do not give up, even though you may think that improvement is slow in coming:

  1. Apply a warm compress to the eyelids for five to ten minutes upon awakening in the morning and before going to bed at night.  Use a clean washcloth and cotton-tipped applicator or commercially available premedicated eye pads to clean the area of the eyelids where the eyelashes join the eyelids.  First, clean the lid margins with the eyelids closed then pull the lower lid away from the eyeball by placing a finger on the cheek below the lower lid and pulling down.  Again, clean the eyelid margin with a cotton-tipped applicator or premoistened pad.  Pull the upper eyelid away from the eye by placing a finger on the eyebrow and pulling upward.  The lid should be cleaned in front of a mirror under good lighting conditions.  Take care not to put the cotton-tipped applicator into the eye.
  2. Take Tetracycline 250mg four times a day.  Continue taking this medication as directed until your next appointment, unless you are specifically instructed to do otherwise.  Should you experience any side effects you think may be attributed to your medication, please call the office immediately.
  3. Apply the prescribed ointment to the eyelid margins twice a day after they have been cleaned and dried.  The ointment should be applied directly to the area of the eyelids where the eyelashes attach.  It can be applied with a clean fingertip or cotton-tipped applicator.  It is common for some of the ointment to get into the eye itself, but this will not be a problem.  The medication contains both a steroid and an antibiotic that are intended for use in and around the eye.  This medication should be used for two weeks only and then discontinued.
  4. Use unpreserved artificial tears (example: Refresh, Seliufresh, Hypotears PF, or Tears Natural Free) every hour while awake.  Continue to use these drops until your next appointment and anticipate their continued use thereafter.  Once your Blepharitis has been brought under control, it will be possible to decrease its frequency while you use these tears and it may be possible to switch you to a preserved artificial tear which is more convenient to use and less expensive.

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