Crusty Bumpy Eyelids: Blepharitis in all its glory
Signs and Symptoms
- Crusty Eyelids (especially in the morning)
- Bumps in your eyelid (stye)
- Dry Eye Symptoms
- Burning, stinging, itching
- Watery eyes
- Fatigues eyes
- Intermittent Blurry vision
- Missing or misdirected eyelashes
- Red Eyelids
Blepharitis, Meibomian Gland Dysfunction, and Dry Eye are all different things, but they are so closely linked that if you have any one of these things you likely have them all (explored in depth here). Blepharitis specifically speaks to the inflammation of the lids (bleph~= lids ~itis= inflammation) most commonly by bacterial infestation. I use the term infestation very specifically, as it’s not truly an infection as the bacteria is part of our normal skin bacteria. We all have many different types of bacteria throughout our bodies, the amount of this bacteria varies greatly between individuals but previous estimates are that there is one bacteria for every cell in our body (interesting read if you’re a nerd like me “Revised Estimates for the Number of Human and Bacteria Cells in the Body”). In blepharitis, the bacteria from our skin is able to get into the hair follicles (anterior blepharitis) or the oil glands (posterior blepharitis) of the eyelid. Here in Alberta, this bacteria is most commonly Staphylococcus Aureus, but it is also quite common for a small parasite called Demodex to be similarly involved. Blepharitis is also highly associated with different skin conditions, such as contact dermatitis, Rosacea, psoriasis, and eczema.
As these bacteria do their thing they create waste products and irritate the surrounding tissue. The inflammation in the area causes the openings of the oil glands to get smaller, making it harder for the oils to come out. As the bacteria damages and changes the oil in those glands, it goes from a nice olive oil consistency to something closer to butter or margarine. Both of these factors affect the oil output of the glands leading to evaporative dry eye. The crusties that you find in the lashes are an accumulation of the damaged oils slowly making their way out of the glands and by-products from the bacteria and the inflammation. These crusties can be bad enough to essentially glue the eyes together first thing in the morning requiring it get moistened and then peeled off.
With the thickening of the oils and the narrowing of the gland openings, it is possible for the gland to become completely blocked and begin to balloon out. This is commonly known as a Stye but can be broken down into either a hordeolum or a Chalazion.
Blepharitis is likely one of the most common ocular conditions here in Calgary. This is not based on any studies, but in any day I work at least 10% of my patients I see complain of these symptoms, and I see at least mild signs of it in another 30-40% who are asymptomatic. Most Calgarians who are asymptomatic are that way because they have had blepharitis so long it’s just become the norm for them and their bodies have actually reduced the number of sensory nerves in the area.
Diagnosis & Treatment
Luckily because blepharitis is so prevalent it is very well understood and has been researched extensively. An impressive protocol of diagnosis and courses of treatment has been set forth by the Canadian Journal of Optometry (even some American regulatory bodies say to refer to this document… Good Job Canada!!).
Diagnosis is typically quite simple as patients will come in with very specific complaints of debris on the lashes or irritation, but the Doctor also has multiple signs that they can notice in a patient. The doctor can usually see the debris on the lashes, but he/she will also notice redness and swelling of the lid. In some of the more significant cases, new swollen blood vessels can even start to form in the areas just outside of the eyelashes. During an annual full exam, it is standard for our doctors to also check the glands of the eyelids by applying some light pressure on the lower lid. This light pressure should be enough to cause some of the oils to spill out of those glands if they are flowing optimally. If no oil comes out of the glands we know something is wrong.
Basic treatment for blepharitis is pretty standardized and focuses mostly on reducing the factors that are causing the inflammation in the first place, typically the bacteria. We do this in several ways, firstly a warm compress is applied with a mild massage, this heats up the thickened oils helping to liquify them (think of butter in the microwave) and the massage helps push the contaminated oils out of the glands making room for newer healthier oil to be made. Immediately after the heat compress and massage you would clean the area with a lid hygiene wipe, to carry away the contaminated oil you just pushed out of the glands and carry away any bacteria which may be on their pilgrimage to have a feast in the glands. Artificial tears drops are typically used to help cover some of the symptoms while the gland flow and health improve, but it also allows for a good base layer for the oils to move out onto. Up to this point, the focus has been on getting the glands flowing again, the next step is kicking the glands into high gear. If we can get the glands flowing fast enough the bacteria will not even be able to get into the glands. Think of those videos you may have seen of bears standing by the river plucking up salmon out of midair as they try to swim back up the stream to spawn. The best way to get the glands flowing as fast as possible is to increase the availability of the oils the body uses to make the oils in the glands. We do this with fatty acid supplementation, but not all fatty acid supplements are built the same and care should be taken in choosing which supplement to use. I have included some links below regarding the effectiveness of these fatty acid supplements. These steps are typically done on a fairly regular basis for about a month in order to get the glands working optimally, and a gradual improvement in symptoms should be noted.
Once the symptoms are gone the frequency of heat compresses, lid hygiene, and artificial tears can be reduced, but should not be stopped. Sadly, enough this is a chronic issue and if you completely stop the treatment it's likely you’ll be back to where you started within a couple months to a year. I usually tell my patients once they are symptom-free decrease the heat mask and wipes to once every two days for about two weeks and see how you feel. If you still feel good after two weeks try doing it every third day for two weeks and etcetera. This way you can find how often you need to do it, as it’s different for each person. With Alberta’s climate and the common bacteria here it's usually not advisable to go any less than twice a week. The frequency need to stay comfortable can also vary depending on the environment, for example when there is a bunch of fires in the Rockies and BC, you may need to do it more often. As you learn to feel what your eyes should feel like when they’re not inflamed and dry, you will learn to notice and adjust your frequency as required.
If the irritation is significant your doctor may also prescribe a medicated drop (steroid, antibiotic, or both in combination) to help get the inflammation under control quicker. This allows for a quicker initial resolution, but these are not typically long-term options because of possible side effects with prolonged use. It is well established that extended use of steroids can induce cataracts, or glaucoma, though short treatment courses while being monitored by your Optometrist is quite safe, and any side effects that arise can be addressed by your Optometrist.
More aggressive forms of treatment exist beyond this such as in-office lid cleaning by your Optometrist (Blephex), manual or mechanical expression of the glands, Oral medications. These options are typically not explored until the above treatments have been unsuccessful, and this can be discussed with your optometrist.
Peer-reviewed articles on the effectiveness of fatty acid supplementation in Blepharitis/Dry Eye