Eyelid Hygiene for the Management of Blepharitis and Associated “Dry Eye”

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 treatment for blepharitis involves eyelid and eyelash hygiene, along with topical antibiotics. Anti-biotic ointments work best because antibiotic 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 that is causing the blepharitis, making recurrences and flare-ups much more common.

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 effective strategies to manage this annoying, ongoing issue. We still need antibiotics in certain difficult 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. In more difficult cases, HOCl can be added to decrease the likelihood of recurrences and flare-ups. (Hypochlorous Acid, also known as HOCl (that 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 is covered in many different types of bacteria. There are certain places where one or more types of bacteria are more likely to be found - the eyes, eyelids and eyelashes are one of those places.

Bacteria like the eyelids because it’s moist there, there’s sugar, lipid, 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, lipid, and protein available. So, the 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. The more bacteria and other debris on the eyelids and eyelashes, the greater the risk of infection, inflammation, and 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 12-24 hours before they die. When bacteria die, they release the toxins that are inside them. These “exotoxins” cause the itching, burning, stinging, campfire feeling 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 minutes to 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. The important thing is to find an eyelid hygiene system that works for you.

As an eye doctor, I prefer products designed for the eyes. Face wash products and eye makeup remover products are designed for a specific purpose and can be too harsh for the eyes. The basic 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. Again, baby shampoo is designed to clean baby hair, and be “gentle” if it should accidentally get in the eyes, but it is 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 on your own eyelids.

Tips for washing your eyes and additional information

Keep it gentle - Some patients hear this description of the problem and think to themselves, “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 cleaner, 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 and 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 eyes closed, using lots of warm water after your gentle eyelid hygiene.

Low-grade blepharitis can masquerade as other eye conditions - Some of the 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 are worsening or if your symptoms don’t resolve within 2-3 weeks, see your optometrist for a follow-up.

You may need help in the form of antibiotics or other strategies they 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

If you live in the Calgary area and you feel you may have blepharitis or dry eyes, please call Doig Optometry to schedule an eye exam. Dr. Chorel and Dr. Doig would be happy to help you with either of these two uncomfortable eye conditions.

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