The treatment of blepharitis
In the fourth of eight articles on common eye complaints, Dr Scott Fraser looks at blepharitis, which can often be almost as frustrating for the GP as for the patient
Blepharitis can be a frustrating condition for patients and practitioners alike. It is a chronic condition that often waxes and wanes over time with symptoms that can seem out of proportion to examination findings.
A stepwise approach
Because of the chronic nature of the disease and the wide variations in symptoms between patients, a stepwise treatment plan can be useful. Most patients will gain relief from the first two or three steps but some will need to progress further. The final step should only be taken in conjunction with an ophthalmologist because of the potential adverse effects.
Step 1: Explanation
Like so many chronic conditions, explanation of the condition and its treatment is perhaps the single most useful management step. It is especially important for patients to understand that the condition is controllable but not curable.
It is easy to get confused with different terms such as anterior and posterior blepharitis, and meibomianitis, but without specialised equipment and a large turnover of affected patients these are difficult to separate accurately. What is much simpler is to think of blepharitis as a dysfunction of the oil secreting meibomian glands with all the signs and symptoms arising from this.
Explain to the patient that these oil-secreting lid glands are not doing their job and that the oil is, instead of flowing on to the tear film, hardening and crusting over the orifices of the glands. This means the lid margin becomes red and sore, chalazia may form because of the inability of the oil to escape and secondary infection may occur.
The patient needs to know it is a lifelong condition that is common but not serious. It is not caused by anything they are doing wrong and will not be helped by vitamins or changing their diet. It is also important to know that symptoms will come and go and there may be long periods when the condition is asymptomatic. During exacerbations, simple strategies such as lid hygiene are usually enough to keep symptoms at bay.
Step 2: Lid hygiene
This is the mainstay of treatment and is surprisingly effective. It can be explained as a method of unblocking the meibomian orifices and allowing the trapped oil to flow more freely. The term lid hygiene is slightly unfortunate and it is worth telling patient this does not imply they have not been washing properly.
It is very useful to give the patient written instructions for lid hygiene – these can be sent out from the local eye department on request or printed off some of the web pages listed below. Initially patients should be instructed to perform the process twice a day, reducing this to once daily as symptoms abate. Most patients then adjust the amount of lid hygiene they do according to their symptoms. It is usually counterproductive to clean more than twice a day as this can cause a mechanical irritation to the lid margins.
There are a number of lid hygiene techniques that can be used and different patients find different methods easier.
The simplest method is to use a moderately hot, clean flannel and press it gently on to the closed lids. This can be held for 15-20 seconds. The intended effect is to 'melt' the solidified oil and gently massage the glands.
A more direct method, but only to be used by more dextrous patients, is to roll a cotton bud along the lid margins in an attempt to clear the meibomian orifices. This is aided by soaking the cotton bud in a 50:50 solution of baby shampoo and cooled boiled water.
Using the same technique, some prefer the cotton bud to be soaked in cooled boiled water with a pinch of salt or a quarter of a teaspoon of sodium bicarbonate (available from chemists) dissolved in a cup of cooled boiled water.
The cotton bud should be used to firmly stroke the skin of the lids towards the lashes,
ie downward for the top lid and upward for the bottom lid. Patients should also be instructed to clean away any crusts that are present on the eyelids, particularly around the roots of the lashes.
Step 3: Tear film supplements
The function of the oil from the meibomian glands is to coat the aqueous tears and prevent them evaporating too quickly. When the glands are dysfunctional, the tears evaporate too quickly and the patient becomes symptomatic from drying of their corneas. This is especially noticeable in dry environments such as centrally heated rooms, smoky atmospheres and when the blink rate is reduced by reading or watching television.
Simple advice can be given such as avoiding situations that exacerbate symptoms. Putting a bowl of water on top of a radiator can temporarily increase the moisture in the room.
Many patients get relief from tear film supplements. Begin with short-acting but non-smeary lubricants such as hypromellose – these should be used whenever the eyes feel sore or dry, which varies widely between patients. It is worth telling patients they cannot overdose on these drops and they are the best judge of frequency of use.
If the short-acting lubricants are giving some relief, but not for long enough, longer-acting products can be used, for instance Viscotears and white soft paraffin LacriLube. Some patients find these can smear the vision for a short while and so should be advised to avoid using them when driving or operating machinery.
Take care with the patient who initially responds well to tear film supplements but then finds their eyes become sore, red or itchy on application. One of the commonest reasons for this is development of an allergy to the preservatives. Try preservative-free drops in these circumstances, for instance hypromellose or carmellose sodium. These products are more expensive and need to be stored more carefully.
Step 4: Topical antibiotics
It is not uncommon to get secondary infection of the meibomian glands in blepharitis and this can be helped by topical antibiotics. These can be given for two to four weeks and should be used immediately after lid hygiene. Ointments (such as chloramphenicol) or gels (fucidic acid) should be used rather than drops as they can be placed at the lid margins and their effect persists much longer. A week's course of topical antibiotics is necessary if conjunctivitis develops (called blepharoconjunctivitis).
It is worth noting that chalazia do not respond well to topical antibiotics. Most will resolve spontaneously over a few weeks – those that do not should be referred routinely for incision and curettage. If the chalazia appears to have a surrounding cellulitis a week's course of oral antibiotics (such as flucloxacillin) may be required.
Step 5: Systemic antibiotics
Oral antibiotics are indicated when symptoms do not respond to the measures above or when there is an associated acne rosacea. They do not work in the short-term but need to be given for at least three months. The standard treatment is oral tetracycline although recommended doses vary; 250mg qds for one month and then bd for two months is an effective regime. Oxytetracycline is an alternative, as is erythromycin if the patient has a problem with tetracyclines. Some prefer to use doxycycline 100mg od for a month and then 50mg for two months.
Patients taking tetracyclines must be warned to protect themselves from the sun because of the risk of photosensitivity.
Step 6: Topical steroids
These can be very effective but should be used for as short a time as possible and only under the supervision of a specialist who can assess the cornea and check the intraocular pressure.
Scott Fraser is consultant ophthalmologist at Sunderland Eye Infirmary and co-author of
Eye Know How (BMJ Books, 2000)
Common symptoms and signs of blepharitis
signs of blepharitis
l Gritty/burning eyes
l Foreign body sensations
l Crusting and matting of the lashes
l Red lid margins
l Chronically red eyes
l Symptoms come and go over time
l Recurrent chalazia
l In-turned lash(es)
When to refer a patient with blepharitis
l Decrease in vision
l Pain (rather than discomfort/irritation)
l Corneal infiltrate/opacity
l Blepharitis in children
l Blepharitis is a long-term condition and patients need to understand that it can be controlled but not cured
l Simple measures usually suffice to make symptoms manageable
l Lid hygiene is the mainstay of treatment
l Tear film supplements can be soothing for some patients
l A short course of topical antibiotics can help. Oral antibiotics should be reserved for more resistant cases
l Topical steroids should not be used without access to specialist eye care facilities
References and further information