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Is it Blepharitis or Dry Eyes?

Jim Kokkinakis
Is it Blepharitis or Dry Eyes?

Suffering from red, scratchy or irritated eyes? Two of the most common eye conditions are Blepharitis and Dry Eyes.  They also can cause significant distress; both physical and emotional.

This is usually because they are inadvertently mismanaged or incorrectly treated.  Even though both these ocular diseases are not curable, they certainly can be brought under control if they are diagnosed and just as importantly treated properly.

One of the key issues to understand is that they are separate conditions.  They can exist together or by themselves.   

Dry eyes can cause blepharitis and blepharitis can cause dry eyes!

Are you confused?  You are NOT the only one. Even many optometrists struggle with this concept.

Another confusing fact is that dry eyes and blepharitis can cause the sclera (white part of the eye) to inflame.  This is called

conjunctivitis, which in this form is not an infection, so it should not be treated with antibiotic eye drops.

Before we go through how to bring these two dreaded disorders under control, they really need to be defined in way that we can all understand.  

Bear with us, it is important to get the complexity of this.  It is why these eye conditions are often mismanaged.

Then and only then will the treatment and the management strategy that we recommend make sense.

What is Blepharitis?

Blepharitis like any "...itis", is an inflammation.  Redness, swelling and discharge on or around eyelid margins can be a type of blepharitis.  This eye condition is quite common but treatment can be difficult, as the cause needs to be determined before taking on this stubborn problem.

Blepharitis Causes

There are five categories of blepharitis:

    1. Staphylococcal - this is bacterial overload.  They release toxins, which in turn inflame the eye lids.

    2. Seborrhoeic - typically this involves flakey, itchy skin arond the eyelids.  There is nearly always the same skin problem on the scalp and eye brows.

    3. Mixed - as this implies it is a combination of the above two conditions.

    4. Lid Rosacea - this seems to be related to the skin condition acne rosacea. There is usually a flush (erythema) on the cheeks, forehead, nose and chin.  A tell tale sign is telangiectatic vessels (spider veins) that are abundant and are obvious on the eye lid margins.

    5. Parasitic - lice or mites can infest the eye lids and eye lashes.  Demodex mites are especially prevalent in blepharitis and skin rosacea.  It is unclear which causes which. Does the presence of blepharitis allow Demodex to multiply or does demodex cause blepharitis?  What is clear is that the mites must be eradicated or controlled to help keep the blepharitis in check.

    6. Dry eyes - can cause ocular surface inflammation which will inflame the eye lid margins.

    7. Eye Drops - excessive use of eye drops, especially those that have preservative can cause a toxic reaction on the ocular surface and the eye lid margins to induce inflammation, blepharitis and dry eyes.


What is Dry Eyes?

The definition of dry eyes has changed over the years.  If we go back to around 2007 The Tear Film & Ocular Surface Society (TFOS) assembled a group of eye care practitioners that were world recognised by their peers as dry eye specialists defined this eye disease as:

"Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface".

This definition was part of a very extensive group of medical papers that were written called the DEWS report (Dry Eye Workshop).  Some 10 years later we are expecting the DEWS 2 report to be published with an adjusted definition. Stay tuned for this but if we are still debating the definition of dry eyes, maybe it is not so simple!

What we have discovered at The Eye Practice, which is very different to other practitioners, is that creating a definition is all well and good but...                       

If the main cause or causes of the dry eye syndrome is not discovered, all you are doing is trying to suppress the symptoms.

This then means a merry go round of bad days and slightly better days.  Try this eye drop and what about these eye drops.

Did you know that the eye drops business is worth $20 billion per year globally!

Eye drops for dry eyes at best just suppress the symptoms, for them just to come raging back.  In many cases we have found that they actually make dry eyes and blepharitis worse!

 

Dry Eye Causes

These include:

  1. Environmental - a low humidity office to frequent flying will not only contribute to dry eyes but also dry skin.

  2. Digital device usage - staring at a smart phone, a tablet of a computer screen causes blinking to slow right down and be inefficient.  This is turn slows down the eyes natural lubrication system and often stops it.  Dry eyes are then inevitable.   

  3. Medication - such as antihistamines, antidepressants and others.

  4. Autoimmune diseases - rheumatoid arthritis, lupus and Sjogrens syndrome.

  5. Rosacea - can cause inflammation around the eye lid margins which in turn will cause meibomian gland dysfunction.

  6. Blepharitis - the eye lids being inflamed can cause a frictional force on the ocular surface and cause the orifices of the meibomian glands to shut down, which in turn causes meibomian gland dysfunction, the leading cause of dry eyes.

  7. Smoking - not much going for smoking is there!

  8. Eye surgery - from eye lid to cataract to laser eye surgery.

  9. Lagophthalmos - is an eye condition in which the eyes do not complete close.  This allows air to dehydrate the surface of the eyes.

Blepharitis and Dry Eyes Treatment 

As mentioned these two eye problems can coexist and treating both is imperative in trying to reach a manageable outcome for any given patient.

We have discovered over many years of experience that the traditional recommended methods of cure not only do not work but can also make things worse.  

Here are some myths that as a profession we need to move on from as the blepharitis and dry eyes epidemic keeps rearing its ugly head:

"If it is dry then wet it!"


There is a massive industry that revolves around eye drops for blepharitis and dry eyes. They do have a role to play but the advice that many of our patients get is if two drops a day doesn't help then keep doubling the dose until you get relief.

Many of the patients that are referred to our clinic are taking more than a dozen eye drops per day.  This only serves to strip the natural oils fro the eye surface and perpetuate the problem.

"Clean your eye lids with Johnson's Baby Shampoo"


Last time I got shampoo in my eyes they stung like hell.  This also strips the oil off the skin and in turn inflamed the eyes in the long term.


Creating a successful treatment plan for an given individual must be on a case by case basis.  We all have heard that dry eyes and blepharitis are multifactorial diseases, but each factor can also affect each individual in a unique way, so customisation is paramount in achieving a satisfactory level of management.

Over the years we have discovered that having the option of delivering any of the following treatments puts The Eye Practice in a unique position to manage these problems.

Blepharitis Options

Blephex

  • Lid Debridement                                                                                                                                                                                                 
  • BlephEx                                                              
  • HypoChlorous acid
  • Tea Tree Oil wipes
  • Manuka Honey
  • Probiotics

Dry Eyes Options

  • Lid Debridement                                                                                           
  • BlephEx
  • Intense Pulsed Light (IPL)
  • LipiFlow
  • MiboFlo 
Lipiflow

There are other supporting treatments as well, but lets not complicate things too much here.

The key issue here is that these eye diseases do not mean a life time on inconvenient and expensive dry eye drops.  Making a comprehensive dry eyes or blepharitis appointment will work out what is going on and get you on the way to getting your life back.


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