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Blepharitis is inflammation of the eyelid margins, the area where the eyelashes grow. It is very common, and in most people it is well controlled with a simple cleaning routine. But some people clean, warm and use drops, and their eyelids are still red, itchy and sticky. This page is for you: we explain why blepharitis tends to come back, what role the Demodex mite plays, and what a dry eye specialist checks and does when home care is not enough.
What does blepharitis feel like?
- Red, slightly swollen or itchy eyelids, especially at the margins.
- Scales or deposits around the base of the lashes, and sticky eyelids in the morning.
- Burning, a gritty feeling in the eye and dryness.
- Vision that blurs and clears with blinking.
- Sometimes lashes that fall out or grow in the wrong direction, or styes that keep coming back.
The symptoms usually appear in both eyes and vary from day to day. They tend to be stronger in the morning.
Two types, and sometimes both together
Anterior blepharitis affects the outer part of the eyelid margin, around the lashes. It is linked to bacteria that live on the skin (most often staphylococci), to seborrhoea (greasy dandruff of the skin and scalp) and to Demodex mites.
Posterior blepharitis affects the inner part of the eyelid margin, where the meibomian glands are (the oil glands that produce the oily layer of the tears). When the glands do not work properly, a condition called MGD, the oil becomes thick, the openings become blocked and the tears evaporate quickly. That is why posterior blepharitis and dry eye often go hand in hand.
Many patients have a combination of both types. This is one of the reasons why treatment aimed at only one part does not bring full relief.
Demodex: the mite behind some stubborn cases
In some people with blepharitis that won't go away, the Demodex mite, a tiny mite that lives in the lash follicles, is involved. A typical sign of it is sleeve-like scales around the base of the lashes, and it does not go away with ordinary washing with soap and water. We explain what the mite is, how it is identified and what may help on a separate page: Demodex in the eyelids. To tell itching caused by blepharitis apart from itching caused by allergy or dryness, see itchy eyes.
The basis: a home routine
According to the American Academy of Ophthalmology guidelines, blepharitis is a chronic condition, and a daily routine is the basis of any treatment:
- Heat. A warm compress on the eyelids softens the oil in the glands and the deposits. It needs to be warm enough and to stay on long enough.
- Cleaning the eyelid margins. Wipes or a dedicated eyelid-cleaning product, used gently along the lash line.
- Lubricating drops, preferably preservative-free if you use them often.
- Skin care. If there is dandruff in the scalp or eyebrows, or rosacea on the face, treating them is part of treating the eyelids.
A home routine helps only when you do it every day, even when you feel well. Stopping usually brings the symptoms back within a short time. And do not put essential oils, tea bags or home-made preparations on the eye: they may irritate it and make things worse.
Why doesn't blepharitis go away?
If you keep at it and still do not feel well, there is usually a reason that can be identified:
- A layer of deposits ("biofilm") made of bacteria, oil and dead skin cells that sticks to the eyelid margin. An ordinary wipe does not remove it completely, and it keeps irritating and blocking the gland openings.
- Demodex that has not been diagnosed or treated.
- Advanced MGD, when the glands are blocked with almost solid oil that heat at home cannot empty.
- Ocular rosacea, an inflammatory skin disease that also affects the eyelids. According to Vieira and Mannis, ocular rosacea is common but is often diagnosed late. See ocular rosacea.
- Another factor, such as an allergy to a product, to make-up or to drops.
What the specialist checks
In dry eye testing, the eyelid margins are examined with a slit lamp (a microscope for examining the eye) at high magnification. The base of the lashes is checked for deposits and signs of Demodex, the eyelid is pressed gently to see whether the meibomian glands release oil and what kind of oil comes out, and the tear film and eye surface are assessed with fluorescein dye. The skin of the face is also checked for signs of rosacea.
The aim is to understand what type of blepharitis you have and what is driving it, because that is what determines the treatment.
What is done at the clinic
At the Dry Eye Clinic in Haifa, the plan is built according to the findings, and often combines several treatments:
- BlephEx, eyelid margin cleaning. A device with a rotating sponge that precisely cleans the eyelid margin and the base of the lashes, removing the layer of deposits that an ordinary wipe leaves behind. It is particularly suitable when there is biofilm, deposits or Demodex. After the treatment you go back to your home routine, which works better on a clean eyelid.
- Meibomian gland expression. When there is posterior blepharitis and MGD, the eyelids are warmed and the thick oil is emptied from the glands. Korb and Blackie also described mechanical cleaning of the lid-margin line, which may improve gland function.
- IPL treatment. When there is MGD, and especially when there is rosacea, broad-spectrum pulsed light on the skin of the face may reduce the inflammation and the dilated blood vessels that feed it. IPL is not a laser. It is usually combined with gland expression.
In addition, the eye doctor may prescribe medical treatment according to the situation: an antibiotic ointment or drops, anti-inflammatory drops for a limited time, a specific treatment against Demodex, or tablets when there is rosacea or significant MGD. The decision is made according to the examination and your general health.
When there is also significant dryness, treating the eyelids is only part of the picture. In such cases the amount of tears and the condition of the eye surface are also checked, and the treatment is matched to the dry eye itself as well.
How to prepare for the examination
A few simple things will help you get the most out of the appointment:
- Prepare a list of all the drops, ointments and products you have tried, including what helped and what did not.
- If possible, come without eye make-up, so that the eyelid margins and the base of the lashes can be examined.
- Tell us about skin conditions (rosacea, dandruff, eczema), styes that keep coming back, and regular medicines.
- If you wear contact lenses, ask in advance whether to come without them.
It is important to set expectations: chronic blepharitis is a condition you manage over time. Even after a good improvement, you usually continue the home routine, and sometimes come back for treatment at the clinic when the symptoms return.
When to see a doctor straight away: severe eye pain, strong sensitivity to light, reduced vision, a very red eye with a pus-like discharge, or swelling that spreads to the whole eyelid and the skin around it. It is also worth being examined if there is a thickening, a sore or loss of lashes in one area of one eyelid that does not improve, or inflammation that appears in one eye only and does not respond to treatment.
In summary
Blepharitis that won't go away is not something you simply have to live with. Behind it there are often deposits, Demodex, blocked glands or rosacea, and each of them has a treatment. A precise examination of the eyelid margins is the step that lets you stop guessing and start treating the cause.
Want a basic explanation first?For basic information on blepharitis: the guide on the Mitzmutz site
Frequently asked questions
Is blepharitis contagious?
Blepharitis itself is not considered a contagious disease. Demodex mites are very common in adults, even without symptoms. Still, it is best not to share towels, make-up or heated eye masks.
Does blepharitis go away completely?
Chronic blepharitis usually does not disappear for good, but it can be well controlled. The aim is to reduce the inflammation and the symptoms, and to keep up a routine that prevents flare-ups.
What are the scales around the eyelashes?
Sleeve-like deposits around the base of the lash are called collarettes, and they are a typical sign of Demodex mites. Softer, greasy scales are sometimes linked to seborrhoea. A doctor can tell them apart when examining the eye under a microscope.
Can I keep wearing make-up?
Usually yes, with care: remove make-up every evening, replace mascara and eyeliner often, and avoid eyeliner on the inner side of the lash line, which may block the oil glands.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Amescua G, Akpek EK, Farid M, et al. Blepharitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P56-P93.
- Liu J, Sheha H, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510.
- Korb DR, Blackie CA. Debridement-scaling: a new procedure that increases Meibomian gland function and reduces dry eye symptoms. Cornea. 2013;32(12):1554-1557.
- Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
- Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed. J Am Acad Dermatol. 2013;69(6 Suppl 1):S36-S41.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.