Blepharitis is a condition involving inflammation and some grade of bacterial infection of the eyelids and the eyelashes. The most common symptoms of blepharitis are:
- Itching
- Burning
- Stinging
- Redness of the eyelid margins
Some patients experience crusting of the eyelashes or discharge, especially in the morning. Unfortunately, blepharitis is notoriously chronic, meaning it comes back again and again, over, and over.
How to treat blepharitis
Traditional blepharitis treatment involves eyelid, eyelash hygiene, and topical antibiotics. Antibiotic ointments work best because medicated eyedrops go into the eye. In blepharitis, the problem is on the eyelids and the eyelashes. So, putting an eyedrop into the eye is like flying over the continent and missing the entire war.
Early in my career, it was a common practice for eye doctors to prescribe an antibiotic in combination with a steroid. Patients loved the steroid in their blepharitis regimen because steroids tell the immune system to calm down and take a little rest and relaxation. Unfortunately, steroids cause cataracts and increase the risk of glaucoma greatly when they are used long-term. Secondly, the steroid/antibiotic combination medicine does not solve the problem causing blepharitis in the first place, making recurrences and flare-ups commonplace.
These risks are the reason I’ve never prescribed steroid-antibiotic combination medications for blepharitis. Instead, I try to educate my patients about the causes of blepharitis and give them practical strategies to manage this annoying, ongoing issue. We still need antibiotics in certain complex cases, but the vast majority of cases can be managed very well with simple techniques that are easy to do at home and don’t require a prescription.
In low-grade cases, simple, nightly, eyelid hygiene is often all that’s needed to prevent recurrences and flare-ups. HOCl can be added in more difficult cases to decrease the likelihood of recurrences and flare-ups. (Hypochlorous Acid, also known as HOCl (which is a small letter “L” at the end) is a new, helpful strategy for managing recurrences of blepharitis). Your optometrist can help you know if antibiotics are necessary.
The risks of developing blepharitis
BACTERIAL LOAD is the greatest indicator of risk for blepharitis. The skin of our bodies home to many different types of bacteria, including many normal, “good bacteria”. There are certain places where one or another type of bacteria are more likely to be found - the eyes, eyelids, and eyelashes are among those places where certain good bacteria are normally found, and also, where some bad bacteria like to hide out.
Bacteria like the eyelids because it’s moist there; there’s sugar, lipids, and protein in the tears to nourish them, and humans don’t clean their eyelids well or often. At night, humans close their eyes and change the environment of the eyelids even more in favour of bacterial growth.
When we close our eyes, the temperature rises, it becomes dark, there’s less oxygen, and the pH shifts. Bacteria love warm, dark, moist environments with sugar, lipids, and protein available. So, the bad bacteria grow and reproduce dramatically overnight while we sleep. That’s why the symptoms of blepharitis are worse in the mornings.
All of this is complicated by the fact that our eyelids and eyelashes are designed to catch things in the air and prevent them from entering the eyes. Dust, dander, pollen, pollution and many other types of debris that float in the air will become trapped on the eyelids and the eyelashes throughout the day. Have you ever noticed that the eyes burn and sting when there’s a forest fire to the west of Calgary, blowing smoke over our city? The more pollen, pollution, bacteria and other debris on the eyelids and eyelashes, the greater the risk of infection, inflammation, and the symptoms of blepharitis.
What causes blepharitis symptoms
Bacterial Exotoxins are the cause of symptoms. Some bacteria can live for days, while most bacteria live for only a few hours. On the eyelids and the eyelashes, bacteria live about 24-36 hours before they die. When bacteria die, they release the toxins that are inside them. These “exotoxins” cause the itching, burning, and stinging that are so common in blepharitis.
The more bacteria that are present, the more bacteria that are around to release their exotoxins when they die. Also, there are more to reproduce. Bacteria reproduce over and over every few hours, creating even more bacteria to release their exotoxins when they die.
While they are alive, bacteria also secrete substances to protect them from your own immune system and give the next generation of bacteria something to stick to. They create a “biofilm” that keeps all the exotoxins in close contact with your eyelid skin when the bacteria die, increasing the severity and the duration of your symptoms.
Nightly eyelid hygiene to help manage blepharitis symptoms
Nightly eyelid hygiene helps immensely! At the start of my career in the 1990s, there were only one or two eyelid cleansing products specifically marketed for the management of blepharitis. Now, there are many. You will hear different recommendations about which is best. Your optometrist can help you decide which products are best for your circumstances. Finding an eyelid hygiene system that works for you is important.
As an eye doctor, I prefer products designed for the eyes. Face wash and eye makeup remover products are designed for a specific purpose and can be too harsh for the eyes. The fundamental problem is this: How do I find a product that’s effective but doesn’t hurt my eyes as I clean my lids and lashes?
In “the old days,” patients asked what I thought of using baby shampoo to clean the lashes. Baby shampoo is designed to clean baby hair and be “gentle” should it accidentally get in the eyes, but it is not designed for the eyes. In my opinion, baby shampoo contains too many components that are too harsh for the eyes. Talk to your optometrist about which product is right for your eyes and the sort of hygiene issue you have with your own eyelids. Here in Calgary, I find most patients prefer eyelid cleansing products that do not dry out the skin leaving it feeling tight and dry. We have enough dry skin in Calgary already!
Tips for washing your eyes and additional information
Keep it gentle - Some patients hear about the problem of bacteria and debris and think, “I want to get rid of all that! I’m really gonna scrub it away!” Please don’t scrub like that. It is possible to scrub hard enough to damage the eyelid skin. Eyelid skin is quite thin and can be damaged easily. It’s not about more pressure - it’s about more time.
If you want to get your eyelids more clean, spend a little more time giving gentle pressure, using a “swirling action” as you wipe across your eyelids and eyelashes. The swirling action will loosen and eliminate the biofilm. Target the lashes- that’s where the debris is. Remember, that’s what the eyelashes were designed for - to catch the debris. You don’t need to, and you SHOULD NOT try to clean inside the eyelids. Clean the eyelashes and the outside of the eyelids.
Rinse it away and rinse well - Some eyelid hygiene products say you can leave them on after you wash your eyes. I disagree. Remember, we are trying to get the debris, the bacteria, the biofilm, and the toxins out of there! I always recommend that you rinse well with your eyes closed, using lots of warm water after your gentle eyelid hygiene. Ten splashes with both hands full of warm water will rinse all the bad stuff away.
Low-grade blepharitis can masquerade as other eye conditions - Some symptoms of blepharitis are similar to symptoms of dry eye or even other infections. If you are having any sort of eye symptoms, see your optometrist first. Once we rule out other infections and obtain a proper diagnosis, we can suggest appropriate treatment and strategies for your circumstances.
After your optometrist has ruled out other eye conditions, they may suggest nightly eyelid hygiene. If your blepharitis is a simple, low-grade case, nightly eyelid hygiene can bring relief within a few weeks. As always, if your symptoms worsen or don’t resolve within 2-3 weeks, see your optometrist in follow-up.
When blepharitis will not resolve with simple eyelid hygiene, you may need help in the form of antibiotics or other strategies we may suggest. Even in the most difficult cases, it is my impression that nightly eyelid hygiene is the number one strategy for preventing recurrence, for the reasons we just discussed. There have been many, many instances when a patient has returned for a follow-up to tell me, “I wish I knew about this hygiene issue earlier. Since I started cleaning my eyelids every night, I don’t need to use those drops all day long.” If your eyes don’t feel better after a few weeks of nightly eyelid hygiene, you should tell your optometrist.
- Dr. Russell W.Doig, Optometrist, Doig Optometry, Calgary, Alberta
Book your appointment today
Don’t let blepharitis symptoms impact your daily comfort and eye health. Most patients can find significant relief from this chronic condition with a proper diagnosis and a consistent eyelid hygiene routine. At Doig Optometry, we’re committed to our Patient Care Priority® approach, ensuring you receive thorough, personalized care for your eye health needs.
If you live in the Calgary area and feel you may have blepharitis or dry eyes, please call Doig Optometry to schedule an eye exam. Dr. Chorel and Dr. Doig would happily help you with either of these uncomfortable eye conditions.