Blepharitis

Overview

Blepharitis is an extremely common condition and can be seen in patients of any age. It is noted in 40% of routine eye examinations, found in 67% of over 60-year olds and is found in 74% of patients who complain of sore eye with screen use. It is linked to patients who have previous chalazia, acne rosacea, ulcerative colitis, IBS, gastritis. Interestingly it is more common in patients with hypercholesterolaemia and carotid stenosis, as well as anxiety and depression.

It is generally a chronic condition but can frequently ‘flare.’ It is primarily a disorder of the meibomian glands which are on the eyelids; on each eyelid there are approximately 20-30 glands. These glands release an oily wax which mixes with the tears, making them less prone to evaporation and more effective. In blepharitis, these glands block, causing two problems,— the gland secretions sit on the eyelids allowing bacteria to multiply causing a chronic inflammation and the oily wax no longer mixes with the tear film causing dry-eye symptoms. For people prone to blepharitis there is no cure and treatment is titrated to a level where it become manageable.

Symptoms tend to be chronic and non-specific:

• Crusting of Lashes
• Ocular Redness
• Foreign Body Sensation
• Chalazion and Stye
• Blurred Vision (often clears with blinking)
• Watery eyes (Often waters excessively to reduce dry eye)
• Burning Sensation
• Acne Rosacea (This is related to blepharitis and coexist frequently)

Please see the attached diagnostic photographs

Who to refer

Outpatient referral for adult cases with ongoing symptoms (who have not responded to treatment outlined below). Have a lower threshold for referral of paediatric blepharitis, who do not respond simple lid hygiene methods and topical antibiotics.

Some patients may require short courses of steroids or long-term treatment with tetracyclines; these patients are best cared for under hospital eye services. Please refer these cases to the outpatient department.

Occasionally blepharitis can cause corneal infections (corneal ulcers) or be severe and sight threatening, if suspected the patient should be reviewed in the BEH Emergency Department. Please see Red Flags Section.

Red Flags

Symptoms which may indicate a corneal infection or sight threatening disease include:

• Increasing pain
• Increasing red eye
• Light sensitivity
• Worsening Vision
• White spot noticed on the cornea (see photograph) 

If this is suspected please refer to the Bristol Eye Hospital Emergency Department.

Before Referral

Lid Hygiene

This is the most important part of treatment; the main problem is meibomian gland dysfunction and lid hygiene is directed to restoring their normal function. Normally treatment will need to be performed for 4-6 weeks to get maximum benefit. 

1. Hot compress and massage. Using a hot flannel or a microwaveable ‘wheat-bag’ to heat the eyelids for around 5 minutes at least 40°C. This melts the oily wax in the meibomian gland, then using a clean finger firmly massage on the eyelids near the eyelashes with the eyelids closed. The massage needs to be done immediately after the hot compress. This can be done once or twice a day when symptoms are bad and reduced in line of symptoms. This will likely need to be done long term. A hot flannel will require frequent reheating, whereas a microwaveable wheat-bag will hold heat longer.
2. Lid Cleaning. Lid cleaning helps remove blepharitis debris and reduces the bacterial burden on the eyelid. The use of baby shampoo has fallen out of favour and may contribute to some of the symptoms. Instead it is recommended to use either clean, cooled boiled water or an over-the-counter formulation. Once the boiled water has cooled use a clean cotton pad dipped in the water to clean at the base of the eyelashes, attempting to remove any crusting or eyelash debris. Over-the-counter alternatives such as Blephagel, Blephasol and Ocusoft (other brands available) claim to have further advantages and are available from most pharmacists. There are OTC blepharitis wipes, however these tend to be more expensive than the OTC gels and foam. Lid hygiene products are non-formulary and should not be offered on prescription. Quality is more important than quantity for lid cleaning and I would suggest patients do lid cleaning daily and then reduce in line with symptoms after three weeks. Often too frequent cleaning can lead to increased irritation. 

Topical Antibiotics

When symptoms flare a prolonged course of antibiotics can be used. Normally chloramphenicol 1% ointment is applied to the eyelid margins BD for 2 weeks (can be up to 6 weeks). This helps reduce the bacterial burden on the eyelids. This should not need to be done long term. 

Lubrication

Blepharitis will often cause significant dry-eye symptoms and topical lubrication can be used to provide symptomatic relief.

This will usually be with

• Hypromellose 0.3% eye drops, Carbomer 980 0.2% eye gel or Carmellose 0.5% eye drops

For severe dry eye (using lubricants over four times a day)

• Carmellose 0.5% or 1% preservative free eye drops
• Hyaluronate 0.1% or 0.2% preservative free eye drops. 

These products are available over the counter and patients are advised to self-care with OTC eye lubricants. Over the counter items should not routinely be prescribed in primary care as per NHS England. 

Oral Treatment

Similar to acne rosacea, tetracyclines can be used to help with moderate to severe blepharitis and BEH is happy for these to be prescribed to patients in the community if confident with the diagnosis. Tetracyclines act to decrease the viscosity of the oily wax from the meibomian glands and have some anti-inflammatory properties. This means while a patient remains on a tetracycline their ‘hot compress and massage’ will be made all the more effective.

Options include doxycycline 100mg OD for 4 weeks, then 50mg for another 1-2 months. Please be aware of contraindications to doxycycline use.

Referral

If referral is required please submit to Ophthalmology via eRS requesting Oculoplastic clinic.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photo

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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