I am blessed with excellent eyesight. With my nearsightedness (myopia) corrected, I was able to see 20/12 the year I applied for my ophthalmology residency. That was two lines better than 20/20! Nearly three decades later, I am still enjoying 20/15 vision and I am doing all I can to stay healthy to protect my excellent eyesight. I wish that being an ophthalmologist provides me with the natural immunity against eye diseases. Not really! In fact, I am at a higher risk for them. Like many of you, I suffer from blepharitis, inflammation of the eyelid margin. I can’t wear contact lens like I used to in my youth because of my blepharitis and I hate the fact that I have to clean my eyelids every night before bed. Do I have a choice? Not really! I do have to do what I preach so I am going to share with you my personal experience in managing my own disease.
Blepharitis can be classified based on the location of involvement (front vs back) or based on causes (bacterial vs oil gland dysfunction vs seborrhea or dandruff). When the skin and the front part of the eyelid margin are predominantly involved, bacteria like Staphylococcus are the most common culprit. Patients typically report burning, itching, irritation like sand in the eyes and crusting along the eyelid margin upon awakening. Scales and matted crusts are often found at the base of the eyelashes which can turn white and even fall off. Eyelid cleaning and antibiotic ointment are the mainstay of treatment. A short course of mild steroid eye ointment can also be very helpful particularly if the inflammation has been around for a long time. Infestations by mites (Demodex) should be suspected in cases when where anterior blepharitis is resistant to regular treatment. Mites crawling along our eyelashes is not very appetizing but a generous dollop of ointment can literally choke the mites to death. Diluted tea tree oil can be especially helpful for Demodex related blepharitis. A commercially available lid wipes, Cilradex, which contains the active ingredient from tea tree oil against Demodex, is far more convenient and less irritating.
Seborrheic blepharitis typically also involves the anterior part of the eyelids but the crusting looks oily or greasy like dandruff. Treatment of the scalp disease can be a great addition to the usual blepharitis treatment regimen in this particular form of blepharitis.
By far the more common form of blepharitis that I see is the posterior form due to oil gland (Meibomian gland) dysfunction. Our tears are much more than salt water. It is a delicate balance of water, oil and mucus. Too little water, too much oil and not enough mucus can all cause tear film instability and secondary dry eyes. The oil/lipid layer is produced by the Meibomian glands and dysfunction of these glands therefore is often associated with dry eyes. Other symptoms include burning, redness, film over vision and recurrent eyelid bumps (chalazion). Examination often show that the opening of these glands are all plugged up.. The coating of the eye might be injected and there might even be tiny erosions on the cornea. If left untreated, the Meibomian glands can scar and shrink with abnormal blood vessels growth into cornea and subsequently scarring as well.
The initial treatment for posterior blepharitis is eyelid cleaning with a hot wash cloth. The heat helps to liquefy the thickened secretions followed by gentle massage and cleaning to express the retained secretions. I typically do this at night when I am brushing my teeth before bed. When I get up in the morning, I usually still have some crusting and I do a quick clean with a hot wash cloth again. Just splashing hot water to my eyes in the shower is usually not enough. When my blepharitis is acting up though, I often times put a dab of baby shampoo in the hot wash cloth which serves to soap up the excess oil and I get more bang for the buck with my cleaning. If that is still not enough, a short course of topical steroid and antibiotic drops almost always do the trick for me. For patients with recalcitrant and severe blepharitis, particularly in individuals with rosacea (a skin condition), oral tetracycline can be a great addition. Oral supplementation with omega-3 fatty acids such as fish oil or flax seed oil have also been shown to be beneficial for some patients with posterior blepharitis and dry eyes. The exact dosage remains to be determined and I generally advise using the manufacturer’s daily recommendation.
More recently, 0.01% hypochlorous acid (Avenova, HyClear etc ) has emerged as an eyelid cleanser to be used for daily lid hygiene. Several small studies showed a reduction in bacterial colonization of the eyelid skin and a decrease in bacterial enzymes activity with its use. I have tried various formulations of hypochlorous acid and found them to be a nice addition to my lid cleaning rituals. However, simply spraying the solution on the eyelids without the cleaning appears to be much less effective in my personal experience.
Several in-office procedures have also become commercially available for the treatment of Meibomian gland dysfunction. LipiFlow and ThermoFlo both combine heat with mechanical squeezing by different mechanisms to achieve the dual objectives. They are particularly helpful for patients who have difficulty in adhering to regular lid hygiene treatment. Intense Pulse light treatment, similar to those that are employed for facial skin conditions have also been used to treat lower eyelid Meibomian glands inspissation. Finally, BlephEx is a handheld instrument with a rotating head that can scrub the Meibomian orifices with or without soap to debride the thickened tissues on top of the glands. For those patient s with steady hands, NuLids is also a compact handheld instrument no bigger than your electric toothbrush that is designed to be used at home. It has a disposable soft silicone tip that scrapes the eyelid margins and a timer that beeps you after 15 secs for a total of one minute of treatment for all four lids.
Blepharitis is a chronic disease and like many chronic diseases, successful management involves healthy habits that are difficult for us human to stick to. There is no magic bullet in the treatment of obesity. Routine exercises and consistent healthy food choices lay the foundation of its treatment. Likewise, while it is exciting to see the appearance of new medicines and devices for the treatment of blepharitis, one is unlikely to achieve symptomatic relief without the very boring daily ritual of lid cleansing. Phillippa Lally, a health psychology researcher at the University College of London, found that it takes an average of 66 days for a new habit to become automatic. There was quite a range too, from as few as 18 days to a whopping 254 days. There needs to be a mental commitment to the grind until it becomes a part of our muscle memory, no matter how many day it takes. Indeed, I think we can translate this kind of dogged perseverance to bring about positive changes in other domains of our life: work relationship, anxiety etc. And as a physician, my work becomes almost trivial when a patient’s good habits take roots. I am mostly there to help you get started and for periodic encouragement.I am blessed with excellent eyesight. With my nearsightedness (myopia) corrected, I was able to see 20/12 the year I applied for my ophthalmology residency. That was two lines better than 20/20! Nearly three decades later, I am still enjoying 20/15 vision and I am doing all I can to stay healthy to protect my excellent eyesight. I wish that being an ophthalmologist provides me with the natural immunity against eye diseases.