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Blepharitis is a very common ophthalmic condition that can cause discomfort and discomfort in the eyes, but with proper knowledge of the condition, it is possible to identify its causes and manage it effectively.

This inflammation of the eyelids often manifests itself with symptoms such as redness, itching and a burning sensation, affecting the daily well-being of the sufferer.

Understanding the main causes, which can range from bacterial infection to allergies or seborrhoeic dermatitis, is crucial to embarking on the right course of treatment. An informed and aware approach can make the difference in managing this problem effectively and improving patients' quality of life.

Classification

Inflammation of the eyelids is an extremely common pathology and is one of the most commonly observed manifestations in ophthalmological clinical practice, even if the patient does not always report subjective symptoms that can be correlated with the pathology.

Blepharitis can present itself as acute inflammationmuch less frequent and quickly resolved, or chronicmuch more widespread and difficult to eradicate.

According to the descriptive classification, Blepharites can be divided into 3 different groups:

- Blepharitis squamosa (or dry): superficial inflammation is characteristically accompanied by the presence of dry scales that give the picture an eczematous appearance.

- Seborrheic blepharitisa major inflammatory reaction is evident, conjunctival hyperemia, dilated eyelid rim vessels, collarettes between the eyelashes and a tendency to madarosis (abnormal loss of eyelashes, and sometimes even eyebrows). This pathology is characterised by the presence of a greasy secretion with voluminous scales and scabs caused by excessive sebaceous secretion.

- Ulcerative blepharitis: inflammation of the eyelid margin with dilated vessels, collarettes, madarosis and inflammation of the eyelash follicles, which appear covered with hardened crusts, inducing bleeding when removal is attempted.

Currently, the most commonly used classification is based on a topographical subdivision, whereby Blepharites are subdivided into front e rear.

It is defined as Marginal blepharitis inflammation affecting both the anterior and posterior margins of the eyelid rhyme.

Main Causes of Blepharitis

Blepharitis can be triggered by a number of factors affecting the health of the eyelids.

Environmental Factors

Environmental factors play a significant role in the development of blepharitis and should be mentioned first and foremost, air pollutionwhich can irritate the eyelids, causing inflammation, and the presence of dust or smoke.

In addition, seasonal allergens such as pollen and moulds can intensify the symptoms of blepharitis. Allergy sufferers often experience a worsening of symptoms during spring and autumn.

Another factor to consider is dry air. Prolonged use of air conditioning can exacerbate dry eyes, a condition often associated with blepharitis.

Bacterial Infections

Bacterial infections are one of the most common causes of blepharitis. Bacteria such as Staphylococcus can colonise the eyelids, causing inflammation and irritation.

These infections can result from poor hygiene, such as not washing your hands before touching your eyes. In some cases, the use of contaminated cosmetics can lead to the presence of bacteria in the eyelids.

It is important to recognise the symptoms of a bacterial infection, such as yellowish secretions and scabs on the eyelids, so that appropriate treatment can be carried out in good time.

Skin Diseases

Certain skin diseases can contribute to the development of blepharitis. Seborrhoeic dermatitis, for example, is a condition that can affect the eyelids and cause inflammation.

Ocular rosacea is also a skin condition that can lead to blepharitis symptoms. This condition causes redness and swelling of the eyelids, as well as a burning sensation.

Symptoms of Blepharitis

Recognising the symptoms of blepharitis is essential for timely treatment. Symptoms vary in intensity and can greatly affect the quality of daily life.

Itching and Irritation

One of the most common symptoms of blepharitis is the itching eyelids. This sensation is often accompanied by irritation and burning.

Itching may be particularly intense in the morning when the eyelids have been closed for a long period during the night's rest. This symptom may also worsen in dry or dusty environments.

Avoiding rubbing the eyes is crucial, as the action can exacerbate irritation and increase the risk of infection.

Redness and Swelling

Reddened and swollen eyelids are visible signs of blepharitis. Inflammation of the eyelid margins can cause these symptoms, often accompanied by a feeling of warmth.

Swelling can vary from mild to severe, affecting appearance and general comfort. In some cases, it can also impair vision, causing fogging.

Secretions and Scabs

Blepharitis can cause sticky eye secretionswhich accumulate along the edges of the eyelids. These secretions can dry out, forming annoying crusts.

This symptom is most evident upon waking, when secretions have accumulated during the night.

Scabs can cause discomfort and, if left untreated, can lead to secondary infections. Regular eyelid washes are essential to maintain hygiene and reduce symptoms.

Diagnosis of Blepharitis

Accurate diagnosis is crucial for managing blepharitis. Ophthalmologists use several methods to identify the presence of this condition and determine its cause.

Clinical Examination

The clinical examination is the first step in the diagnosis of blepharitis. The doctor carefully examines the eyelids and ocular surface, looking for signs of inflammation.

Visual inspection allows redness, swelling and the presence of scabs to be detected.

In some cases, the doctor may ask the patient to describe the symptoms and their severity in order to get a clearer picture of the condition.

Laboratory Tests

These tests may involve taking samples of secretions from the eyelids.

The samples are analysed to identify the presence of bacteria or other microorganisms, and thus to determine whether a bacterial infection is the cause of the blepharitis.

Laboratory tests can also help rule out other ocular conditions, ensuring that the prescribed treatment is targeted and effective.

Blepharitis therapy

The rationale for Blepharitis therapy can be divided into several stages:

1) Modify environmental and working conditions that may increase the evaporative process of the tear film.

2) Improving the quality of the tear film, which is altered due to lipid deficiency, typical of Meibomian gland dysfunction.

3) Treat the resulting inflammatory process of the ocular surface.

4) Treat any infection/infestation of the eyelid margin.

5) Improving the rheology of the secretion of the Meibomian glands and reducing the inflammatory component.

Treatment of blepharitis in patients with Meibomian gland dysfunction, characterised by evaporative dry-eye, begins with improving environmental conditions, increasing humidity levels and avoiding conditions with excessive room heating or air conditioning. In addition, it is a good idea to increase the intake of foods or supplements containing omega-3 fatty acids.

The use of artificial tears plays a fundamental role in the treatment of symptoms in subjects suffering from Meibomian gland dysfunction; alterations in the tear film are generally related to the lipid deficit, a direct consequence of gland dysfunction, with an evaporative dry-eye.

The lipid layer performs numerous functions in the constitution of the tear film:

1) stabilises the tear film

2) thins the aqueous phase (Mangoni effect)

3. delays the evaporation of tears

4) provides a coating to the cornea

5) forms a barrier to external particles

6) has antimicrobial activity

7) seals the eyelids during prolonged closures (night lid-lag).

Therefore, it makes sense to replace the deficient lipid portion. The use of artificial tears is recommended, preferably without preservatives, possibly with a lipid content or lipid micelles that can replenish the tear film and reconstitute the superficial lipid layer to reduce evaporation processes.

Evaporative dry-eye resulting from dysfunction of the Meibomian glands in patients with chronic blepharitis is responsible for the onset of chronic inflammation that leads to an aggravation of symptoms.

Chronicisation of the process is a consequence of metalloproteinase activation with release of pro-inflammatory cytokines, increased tear film instability and cell damage.

Therefore, moderate use of corticosteroids, preferably surface corticosteroids, to interrupt the inflammatory cascade is appropriate in these subjects. The use of these corticosteroids can be carried out with a dosage of twice a day for 7 - 10 days a month, to be repeated for 3 - 4 months, obviously monitoring any side effects. The dosage can however be modified according to the patient's clinical features, and even prolonged for months, possibly diluting the cortisone eye drops to prolong their use.

In patients with Meibomian gland dysfunction, the persistence of superficial secretion not fully expressed in the conjunctival sac contributes to a pabulum of culture on the eyelid surface, resulting in possible overinfection by opportunistic pathogens for which local antibiotic therapy and careful cleansing of the eyelid margin is recommended.

In these clinical conditions, it is important to perform proper eyelid edge hygiene with warming of the eyelid (minimum 4 minutes, 1 or 2 times a day) to overcome the melting point of the glandular secretion followed by eyelid massage in order to purge the Meibomian glands. It may also be useful to cleanse the eyelid edge with products based on hypoallergenic, pH-neutral cleansers or oil extracted from the tea plant, which has antibiotic properties.

Recently introduced in Italy is a device that allows the distribution of heat on the eyelid combined with a massage that improves the trophism of the Meibomian glands.

Demodex, a mite responsible for some chronic blepharitis, can also be treated with a combination of systemic Ivermectin and Metronidazole in forms resistant to conventional treatment.

The use of oral Minocycline (tetracycline) is able to improve the inflammatory process by reducing cytokine levels (IL-6, IL1 beta, IL17 alpha, TNF alpha, IL17p70) after 2 months of treatment.

The use of Minocycline also showed an improvement in tear film stability, with biological changes on fatty acids. Reduction of a branched-chain fatty acid (ISO C20) with improvement of BUT was observed.

A great deal of work can be found in the literature to improve blepharitis therapy. Among the substances studied in recent years is the use of topical Azithromycin, an antibiotic responsible for an improvement in symptoms, redness and swelling of the eyelid margin. This would be due to both the antibacterial action of the antibiotic and the anti-inflammatory properties of Azithromycin itself.

The improvement in the degree of occlusion of the Meibomian glands and the characteristics of the glandular secretion are, however, likely due to the physical change in the secretion.

The mechanism of action of Azithromycin on lipids in Meibomian gland secretions may be related to the inhibition of tissue and glandular lipases that degrade lipid structure.

The 'anti-lipase' action of Azithromycin is, however, achieved with lower drug levels than the antibacterial ones.

Home Remedies

Home remedies can be effective in managing mild symptoms of blepharitis. Here are some suggestions:

1. Applying warm compresses on the eyelids to relieve inflammation and remove scabs.
2. Eyelid washing with a mild solution of mild soap and water to maintain hygiene.
3. Avoiding make-up during blepharitis outbreaks to reduce the risk of aggravating the inflammation.

Following these simple tips can help manage symptoms and prevent further complications.

Prevention and Care

Preventing blepharitis is possible by adopting a number of good habits. Proper hygiene and management of triggers are essential to minimise risks.

Daily Hygiene

Maintaining good daily hygiene can significantly reduce the risk of blepharitis. Regular washing of the face and eyelids, using mild soaps, is essential.

Not touching your eyes with dirty hands can prevent the introduction of bacteria. Changing pillowcases often helps maintain hygiene.

These simple practices help maintain healthy eyelids, reducing the incidence of blepharitis.

Avoiding Triggering Factors

Identifying and avoiding triggers is another crucial step in preventing blepharitis. Here are some tips:

• Avoid dusty or smoky environments to reduce irritation of the eyelids.
• Limit contact lens wear when the symptoms are active.
• Adopting a healthy lifestyle and a balanced diet to support ocular health.

Following these recommendations can reduce the risk of developing blepharitis and improve overall eye comfort.

On the subject of eyelid infections, see also:

• Chalazion: causes and remedies - Oculista Italiano
• Stye: causes and prevention - Oculist Italiano
• Eyelid dermatitis: how to prevent it - Oculista Italiano

• Research in dry eye: report of the Research Subcommittee of the International Dry Eye Workshop (2007) Ocul Surf. 2007;2:179-193.
• Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and treatment. Ocul Surf. 2009 Apr; 7(2 Suppl):S1-S14.
• Benitez del Castillo Sanchez JM, Del Rio Novo MT, Garcia-Sanchez J. Frecuencia de la blepharitis en la consulta ophthalmologica diaria. (Blepharitis prevalence in dairy ophthamic practice) St Ophthal. 1999;XVIII(3):225–230. Spanish.