Simon G Levy

Consultant Eye Surgeon
Reassuring Personal Care - Advanced Technology - Specialist Cataract and Refractive surgeon

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 throat.

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.

Normal eyelid - meibomian gland openings are seen as a row of dots behind the eyelash roots

Normal upper and lower eyelid glands shown by meibography

What is blepharitis?

Blepharitis (also called meibomian gland disorder or MGD) is a disease of the eyelids and eye surface. It mostly affects 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 often a major element of the problem. This may explain why many blepharitis patients have the skin disorder Rosacea in which Demodex is also important.

Demodex mites (arrows) on an eyelash root (asterisk)

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.

Blepharitis - eyelash root deposits found in Demodex infestation

Blepharitis - swollen, infected gland openings

Blepharitis - red eye during flare-up

Blepharitis - swollen lids during flare-up

Blepharitis - eyelid cyst

Blepharitis - concretions under the upper Iid

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 working normally.

The symptoms of dry eye are similar to those of blepharitis.

Primary dry eye - Lissamine Green dye stains inflamed areas of the eye surface

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 surgically.

Conjunctivochalasis – abnormal folds of tissue between the eye and lower lid

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.

The abnormal area in SLK is under the upper eyelid and stains with Lissamine Green


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:

Ocusense tear layer analyser precisely quantifies eye surface dryness

Inflammadry Matrix Metalloproteinase 9 device (left) identifies eye surface inflammation. Normal (middle) and abnormal (right) result

Microscopy of eyelash roots shows Demodex mite infestation in this patient (left). Head of Demodex mite at high magnification (right).

Meibography (imaging of the meibomian glands) of normal (left) and severely damaged (right) glands

Treatment overview

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.

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, see below.

Amniotic membrance patch

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 you.

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.
Lidcare wipes.
Biotrue lid wipes by Bausch and Lomb.
Blink lid-clean by Abbot Medical Optics.
Lumecare eyelid wipes by Lumecare.

Eyelid wipe

(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 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 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.

Using a cotton bud to empty eyelid glands

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
Hylotears/Hyloforte Geltears  
Vismed Liposic  
Oculotect Liquivisc  
Hycosan Clinitas gel  
Celluvisc – 0.5% or 1.0% Vismed  
Liquifilm Thealoz Duo  
Blink Theratears  
Refresh Lubristil  
Systane Hydramed  
PF Hypromellose 0.3%    
Thealoz Duo    
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.

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 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 or t: 0845 330 7556

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.

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.

Blephademodex and Cliradex contain an extract of Tea Tree Oil called 4-Terpineol with strong anti-Demodex activity. Oust Demodex is based on Tea Tree Oil. They come as a self-treatment towlette or foam, for wiping the face and eyelids once or twice daily usually for three months. A doctor’s prescription is not needed.

Cliradex treats Demodex mite

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).

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.


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.

A high tech Lipiflow applicator

The Lipiflow device controls the applicator

IPL is an important new technology. I use an IPL designed for eyelid work – the Lumenis M22 with Optimal Pulse Technology. This delivers laser-like focused light of selected wavelength and intensity, improving the performance of the meibomian glands by multiple modes of action: it opens blocked glands, shuts down abnormal eyelid veins that promote inflammation and kills Demodex mite. IPL helps in long term management by maintaining a low level of symptoms and reducing the need for cumbersome home treatments and medications. It may improve long term prognosis by protecting 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 downtime afterwards.

Lumenis M22 IPL

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.

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 often works well. Other agents used for this quite common problem are Amitriptyline and Pregabalin.