Understanding blepharitis and dry eye
Understanding the normal tear film and eye surface
The eye and the structures around it, such as the eyelids and lacrimal gland, work together to produce
the tear film. A healthy tear film is essential – it lubricates the eye surface, provides it with nourishment
and oxygen and contains antibacterial agents. The tear film isn’t a simple layer of water but a complex
mix of water, lipids (oils), mucous and antibacterial proteins. The lacrimal gland (located behind the eye,
so it cannot be seen) produces water and antibacterial proteins, the meibomian glands (in the eyelids)
produce lipid and the mucous comes from numerous cells on the eye surface. The tear film is not static
– it is constantly renewed, spread over the eye surface by blinking and then discharged into the tear
ducts. The tear ducts open on the inner corner (nose side) of the eyelid and pass to the back of the
More about meibomian glands
These are important as they make the lipid needed to stabilise the tear film. The 20 or so glands in each
eyelid can be seen using an imaging technology called meibography. Their pores open on the eyelid rim
near the base of the eyelashes.
What is blepharitis?
Blepharitis (also called meibomian gland disorder or MGD) is a disease of the eyelids and eye surface. It
mostly aff ects older adults (40 years and up) and is probably the commonest eye disorder.
The root cause is malfunction of the meibomian glands, several processes acting together: 1. Infestation
of the meibomian glands and eyelash roots with Demodex mite. This incites inflammation directly and
also indirectly as it harbours a toxic bacterium called B. Oleronius. 2. Low grade bacterial and fungal
infection of the meibomian glands and eyelid rims. 3. Changes in the structure and performance of the
meibomian glands such as narrowing of their openings and production of sludgy poor quality lipid.
The mix varies between patients. Demodex infestation is oft en a major problem. This may explain why
many blepharitis patients have the skin disorder Rosacea in which Demodex is also important.
Other diseases of the eyelids and eye surface such as conjunctivochalasis and superior limbic keratitis
(see below) may co-occur with blepharitis, increasing its impact.
Children and young adults also get blepharitis but it is rare. At this age the cause is bacterial infection of
the meibomian glands.
Once initiated, blepharitis may be self-perpetuating. The damage done to the delicate architecture of
the glands induces inflammation which causes more damage and so on. The meibomian glands may
block up, gradually shrink and stop working and ultimately disappear altogether – a highly untoward
circumstance given their importance.
Although it originates in the eyelids, blepharitis causes eye symptoms. Why? Because inflammation of
the eyelids spreads onto the adjacent eye surface. Also the blocked meibomian glands release less lipid
for the tear film, which equates to less lubrication so the eyelids rub against the eye surface with every
blink. Moreover the lipid normally reduces evaporation of the water component of the tear film so
blepharitis causes a secondary dry eye.
There are many symptoms: redness, irritation, soreness and even pain, a feeling of dryness, scratching
and grittiness, itching, paradoxical watering (eye irritation causes tearing, plus the tear film is unstable
and so trickles over onto the eyelid), mattering (debris accumulates on the eye surface) and intermittent
blurring of vision (from smearing of the tear film). Symptoms are worse in air conditioned environments
and when reading, watching TV and other prolonged visual tasks during which blink rate drops. Contact
lenses tend to exacerbate blepharitis and wearing them may be difficult. Episodic flare-ups occur when
all the symptoms are worse and the eyes may be very red. Eyelids cysts called chalazia that don’t go
away by themselves are common. Calcium deposits under the eyelids called concretions may scratch
against the eye causing a foreign body sensation. Fortunately permanent eye damage is rare in adults.
However childhood blepharitis is different and may cause significant eye damage unless treated.
What is dry eye?
Dry eye is caused by reduced water in the tear film. Primary dry eye signifies less production of
water by the lacrimal gland. Usually this is age related and more frequent in women. Occasionally
rheumatological disorders such as Sjogren’s syndrome or rheumatoid arthritis damage the lacrimal
gland. Secondary dry eye, accounting for around 90% of cases, is due to blepharitis – reduced
meibomian gland lipid allows greater tear film water evaporation even when the lacrimal glands are still
The symptoms of dry eye are similar to those of blepharitis.
What is conjunctivochalasis?
This is stretching and folding of the conjunctiva, the lining of the white part of the eye.
Conjunctivochalasis is age related but worsened by the inflammation caused by blepharitis. The folds
are typically located along the lower eyelid margin and are too fine to be seen. During blinking they
are crushed between the upper and lower eyelids, becoming inflamed and sore. Watering is another
problem as the folds block the tear duct openings. Conjunctivochalasis can be cured by removing it
What is superior limbic keratitis (SLK)?
In SLK the upper eyelid rubs against the eye causing a local patch of inflammation. SLK is often
associated with blepharitis and dry eye. It may cause considerable discomfort. Treatments include a
wide diameter contact lens to prevent rubbing and surgery to remove the abnormal patch.
In clinic I will examine your eyes and may apply eye drops such as Lissamine Green that reveal the extent
of eye surface inflammation. I provide a comprehensive suite of specialist investigations for blepharitis
and dry eye:
After I have examined your eyes and seen the results of your tests, we will discuss a strategy suitable for
you – this needs to be individualised as there isn’t a formula that works for everyone.
In older adults blepharitis and dry eye are long term conditions that can’t be cured. However symptoms
can usually be reduced to an acceptable level. Treatment is needed for two clinical scenarios: 1. Settling
flare-ups. These may be very unpleasant and some patients (a minority) get them quite often. 2. Long
term management. Here the aims are to minimise daily symptoms and to prevent damage to the
meibomian glands so they remain functional.
Childhood blepharitis usually is curable although prolonged treatment (up to several months) with oral
antibiotics and sometimes eye drops may be needed. Relapses do occur but these usually respond to
Treatment of flare-ups
I use various approaches depending on individual circumstances: 1. Steroid eye drops (unpreserved),
Tetracycline or Azithromycin antibiotic tablets and sometimes antibiotic eye drops. These may be
needed for a month or longer. 2. A thin patch of amniotic membrane (a naturally occurring material
with powerful anti-inflammatory properties) placed on the eye. 3. Intense Pulsed Light (IPL) therapy,
Long term management
Management ranges from simple non-medicated self-treatments to therapies of various types that I
provide. You will hope to be symptom-free or at least for the nuisance to be minimised. You should
also be aware of the need to protect the meibomian glands from gradual damage that may reduce
their function – monitoring is done by occasional imaging with a meibography device. The strategy
endeavours to achieve both ambitions using a combination that will be convenient and effective, for
1. Unblocking the meibomian glands: self-treatment
Unblocking the glands allows their lipid to reach the eye surface and helps clear Demodex mite and low
grade bacterial and fungal infection inside them. Self-treatment should be done once or twice daily,
depending on symptom severity. The three stages are a) unblocking the meibomian gland openings
b) loosening the lipid stuck inside the glands and c) massaging the lipid out of the glands.
a) Unblocking the meibomian gland openings, by wiping the rim of the eyelid. A cotton wool bud can
be dipped in a solution of baby shampoo or bicarbonate of soda and rubbed gently along the rim of
the eyelid. However commercial eyelid wipes, available from chemists without a doctor’s prescription,
work better. Use them according to the manufacturer’s instructions. This list isn’t comprehensive as new
agents come and sometimes go. The same applies to eyelid warmers and artificial tears.
Ocusoft wipes. Two types are available. Use Ocusoft Plus for a month then switch to Ocusoft Original.
Purchase from a pharmacy or from the importer Scope Ophthalmics t: 01293 897209.
Blephaclean wipes. Purchase from a pharmacy or from the manufacturer Spectrum Thea
t: 0845 521 1290.
Systane or Supranettes wipes by Alcon.
Biotrue lid wipes by Bausch and Lomb.
Blink lid-clean by Abbot Medical Optics.
Lumecare eyelid wipes by Lumecare.
b) Liquefying the abnormal thickened lipid stuck in the glands, by eyelid warming. A flannel or small
towel soaked in hot water from the tap can be held against the closed eyelids for a while. This is
adequate but obviously imprecise. Much better ways are:
The EyeBag & the Eyebag Instant. Eye masks that are microwaveable/re-usable and self-warming/
disposable respectively. Order from the Eyebag Company at www.eyebags.com or t: 01422 346116.
TheraPearl eye masks are microwaveable/re-usable and can also be frozen for comfort. They are
made by Bausch and Lomb.
Tranquileyes Beads/Instants/Advanced by Scope Ophthalmics.
Blephamask is microwaveable/re-usable. Order from Mid-Optic at www.midoptic.com or
t: 01332 295001.
Bruder eye hydration compress by Bruder Healthcare.
The eye doctor/The eye mask by The Body Doctor.
Blephasteam goggles. A pair of goggles forms a seal around the eyes and the air surrounding the
eyelids is warmed to soft en the material stuck in the eyelid glands. It costs about £200.00. Order
online or t: 0845 521 1290.
c) Emptying the eyelid glands, by massaging the lids. It is essential to (gently) force the now liquefied
material through the now unblocked openings and so out of the glands – otherwise it will just harden
again and stay stuck. The eyelid glands are arranged vertically with their openings on the rim of the
eyelid next to the base of the eyelashes. To empty the glands, massage the eyelids from either the
bottom to the top (lower eyelid) or from the top to the bottom (upper eyelid). Do this by gentle rolling
movements, done two or three times with a finger or cotton wool bud, moving along the length of the
eyelid until the whole eyelid has been massaged. By ‘gentle’ I mean firm but comfortable – don’t press
hard! There’s no point in massage without doing eyelid wipes and warming first. If you have just had
eye surgery stop self-treatment and ask your ophthalmologist when to resume it.
2. Increasing lubrication: artificial tears, gels and sprays
Artificial tears (lubricating eye drops or comfort drops) are the mainstay of treatment for dry eye and
useful for blepharitis. They are available without a doctor’s prescription from any pharmacy. Lubricating
eye drops replace the water missing in dry eye and blepharitis and contain other substances that
improve the tear film. They are non-medicated and may be used frequently ie up to every hour. A
standard regimen might be four to six times daily. Apply one or two drops each time.
Lubricating eye gels are similar but thicker, staying longer on the eye and trading the convenience of
less frequent administration with a tendency to smear vision. Lubricating eyelid sprays are easy to use
but probably not as effective as other formulations and eye make-up might be a problem.
Lubricating agents are available with or without preservative. Preserved versions are cheaper, but the
preservative is abrasive (after all it is intended to kill bacteria) and not especially good for the eye. If you
are applying these agents more than once or twice daily you should use an unpreserved agent. These
are packaged in small individual containers or in airtight bottles that are safe for long term use (follow
the manufacturer’s instructions). This list of lubricating agents that are unpreserved or have a gentle
preservative is not all inclusive:
|Artificial tears||Carbomer gel (generic)||Clarymist|
|Hyabak||Viscotears (unpreserved available)||Eyelogic|
|Celluvisc – 0.5% or 1.0%||Vismed|
|PF Hypromellose 0.3%|
|Optive and Optive Plus (the Plus version is for blepharitis)|
Devices to help apply eye drops
If you find it difficult to apply eye drops, consider using an ingenious device called Opticare. This is
an eye drop applier that is easy to use and works with most standard-sized bottles. You should show
the eye drops you are using to the pharmacist before you buy Opticare, in case your bottle won’t fit.
The pharmacy will order it (or sell any similar device it has) or buy it yourself online or by calling the
manufacturer Cameron Graham Ltd t: 01484 667822. Hylotears and Hyloforte will not fit this device.
Compleye is an eye drop applier specifically designed for them. It is inexpensive and your chemist will
order it or alternatively get it online or from the manufacturer Scope Ophthalmics t: 01293 897209.
3. Anti-inflammatory food supplements: Omega 3 and 6
Omega 3 and 6 fatty acids are plentiful in fish oil and plant oils such as flax seed. They may reduce eye
surface inflammation from blepharitis and dry eye. It is not possible to give advice on specific Omega
3 and 6 supplements, commercial preparations or quantities. I suggest you buy Omega 3 and 6 tablets
from a health food store and take the manufacturer’s recommended dose. An example is Viteyes
Omega Blend which is designed for blepharitis. Order them from your pharmacy or the distributor
Butterflies Healthcare at www.viteyes.co.uk or t: 0845 838 6724. Even if they don’t help your blepharitis
they might be good for your general health!
Omega 3 is available as an innovative eye drop called Remogen. Its effectiveness compared to oral
preparations is unknown. Order from TRB Chemedica (UK) Ltd at www.trbchemedica.co.uk or
t: 0845 330 7556
4. Retaining tear film water: tear duct plugs
Tear duct plugs are very small, soft plastic devices inserted into the tear duct openings on the inner
(nose side) of the eyelid rim. They stop tear film water draining from the eye via the tear ducts and are
a useful treatment for dry eye. Insertion is quick and done in outpatients. The plugs are invisible and
can’t be felt. If they help but have fallen out (which often happens) the tear duct openings may be
permanently blocked by a small surgery.
5. Anti-inflammatory medication: Ciclosporin
This is an effective eye surface anti-inflammatory and safe for long term use (unlike steroid eye drops
which are only ok for short to medium usage in most cases ). I usually prescribe Ikervis (Ciclosporin 0.1%
drops in a pharmacologically advanced formulation) which is used once daily, at night. It sometimes
stings. In the UK the alternative formulation is Optimmune (Ciclosporin 0.2% cream) used up to three
times daily. In the USA ophthalmologists prescribe Restasis (Ciclosporin 0.05% drops). Ciclosporin takes
up to six weeks to reach its maximum effect. You may need it for six months or longer.
6. Treating Demodex mite infestation: Cliradex and Oust Demodex in clinic and self-treatment
Cliradex is an extract of Tea Tree Oil called 4-Terpineol with strong anti-Demodex activity. Oust
Demodex is based on Tea Tree Oil. I apply their fortified versions directly to the eyelids for a few
minutes in clinic under direct observation. They come also as a self-treatment towlette and foam
respectively, for wiping the face and eyelids once or twice daily usually for three months. A doctor’s
prescription is not needed.
7. Treating Demodex mite infestation: Ivermectin and Metronidazole tablets
I prescribe short courses of these agents to treat Demodex infestation of the eyelashes and meibomian
glands. Metronidazole is a commonly used antibiotic. Ivermectin is an effective antiparasitic agent
whose discoverers were awarded the Nobel Prize for Medicine in 2015. It has been very widely
used since 1981 to treat many parasitic diseases. The use of Ivermectin tablets to treat blepharitis is
unlicensed in the UK, but this does not mean it is ineffective and Ivermectin tablets have an excellent
safety profile. You will be interested to learn that Ivermectin cream is licensed to treat Demodex in
Rosacea (the trade name is Soolantra).
8. Cleaning the eyelid margin: Blephex
This is a cleaning device whose soft ,foam-tipped rotating head is soaked in detergent and used to
gently scrub heavily crusted eyelashes and eyelid rims and open the pores of the meibomian glands. I
use it on its own in clinic or immediately before Lipiflow.
9. Unblocking the eyelid glands: Lipiflow
This sophisticated technology unblocks the eyelid glands. An applicator warms them to the precise
temperature at which the blockage liquefies and mechanical rollers squeegee it out, allowing the
glands to function again. It is safe, fast (treatment takes twelve minutes) and doesn’t hurt. Symptoms
improve for six to twelve months. Lipiflow empties blocked eyelid glands more effectively than self treatment
and is more convenient, requiring clinic visits once or twice each year compared to a twice
daily routine at home.
Superior eyelid gland emptying reduces symptoms and may also improve the long term prognosis of
blepharitis. Why? Blockage damages the delicate architecture of the glands – unless it is successfully
relieved they may largely stop working and disappear, so worsening the condition.
10. High tech new treatment for blepharitis and dry eye: Intense Pulsed Light (IPL)
IPL is an important new technology. It is used also by dermatologists for Rosacea a disorder linked to
blepharitis and is highly effective. I use an IPL designed specifically for eyelid work – the Lumenis M22
with Optimal Pulse TechnologyTM. This delivers focused light of selected wavelength and intensity and
has multiple modes of action: it opens blocked meibomian glands, shuts down abnormal eyelid veins
that promote inflammation and kills Demodex mite. IPL is helpful in both fl are-ups (to reduce redness,
discomfort, watering etc) and long term management (to maintain a low level of symptoms and
protect against meibomian gland drop out). Usually three to five sessions are needed about a month
apart. IPL is done in outpatients, normally causes no significant discomfort or after effects and there is
no down time afterwards.
11. Fingerprick autologous blood (FAB)
This is a new treatment. Blood contains powerful anti-inflammatory substances. Normally these are
inside our blood vessels and only small quantities reach the eye surface. ‘Autologous’ means ‘treatment
with something derived from our own body’. FAB is done by pricking a finger up to four times daily in
the same way that diabetics check blood sugar levels – with an automated finger pricker which is quick,
easy and painless. A drop of blood is squeezed out and applied straight from the finger onto the eye.
Many patients enjoy considerable relief from FAB although it does require commitment.
12 Hypersensitive eye pain
Some people with mild blepharitis and dry eye nonetheless experience severe discomfort. This is thought
to come from excessive sensitivity of the eye’s sensory nerve fibres. Actually many lucky people have the
opposite circumstance – the eye is less sensitive than normal. It isn’t known why hypersensitivity happens
and there isn’t a way of re-establishing normal sensory nerve behaviour. However several therapies
tackle the problem by diminishing the brain’s awareness of the ‘false discomfort’. I prescribe Duloxetine
and find this oft en works well. Other agents used for this quite common problem are Amitriptyline and