Good Hope Eye Clinic

Blepharitis Blepharo- keratoconjunctivitis (& eyelid ocular rosacea)

David Kinshuck & colleagues

What is blepharitis?

Blepharitis is the medical term for inflamed eyelids. The inflammation is like eczema of the skin, with red, scaly eyelids. You may notice tired, or gritty eyes, which may be uncomfortable in sunlight or a smoky atmosphere. They may be slightly red, and feel as though there is something in them. The eyelids have tiny glands in them, especially the lower lids. These glands make substances that mix with tears, and help the tears to spread across the eye. There may be fungi in the lids Eye 15, or demodex mite.


meibomian glands, diagram, side view

side view

meibomian glands, diagram, front view

front view









The glands in the eyelids shown in purple


This thin layer of tears lubricates the eyes, stops them drying out, and keeps them comfortable.


healthy tear film, side view

side view

healthy tear film, front view

front view









Evenly spreading tears: a comfortable eye

However, as you get older, and particularly if you have dry skin, these glands can block. As a result the glands do not make the chemicals that enables the tears to  spread evenly across the front of the eye. As a result, the tears break up, and dry patches develop develop on the surface of the eye. These patches make the eyes feel sore or gritty.

Blepharokeratoconjunctivitis (ocular rosacea) may occur in adults or children. There is often a long delay getting treatment.

  • Lid margin may not be inflamed, lids..anterior or posterior involvement.
  • may be asymptomatic
  • Chalazia..posterior lid
  • hypersensensitivity..anterior lid
  • lid...styes...staphyloccus contributes.
  • On the lids there is crusting, telangiectasia, phlyctentules  papillary hyperplasia, hyperaemia
  • corneal ...crystal, marginal infiltrates, punctate epitheliopathy, axial corneal scar, vascularisation, phlyctenules, thinning.
  • need to exclude Molluscum, allergic, chlamydia, ligneous conjunctivitis
  • there may be skin flakes; collarettes suggest demodex as below


This may cause or contribute to the blepharitis

  • if there are collarettes, scrape lid and look for demodex
  • recurrent chalazion scrape margin similarly
  • there may be keratinisation
  • 2 types of mite,
    1. one causes the blepharitis  
    2. one causes chronic chalazion/ multiple chalazion in children
  • demodex is linked to rosacea and loss of lashes


poor tear film in blepharitis

side view

poor tear film in blepharitis

front view









Poorly spreading tears: dry patches develop on the surface of the eyes making them sore.


Grading severity

The condition can be graded (ARVO 2010)

  1. mild...noticed by the doctor only. No treatment needed, except may need to treat just prior to cataract surgery. A healthy diet with a little fish is helpful as below.
  2. moderate
    • when the treatments below are needed...lid cleaning/antibiotic cream/lubricants.
    • more severe cases may need short courses of steroid creams for the eyelid.
  3. Corneal involvement, with pannus (blood vessels growing in on to the surface of the cornea)..may need more steroid and antibiotic tablets.


Blepharitis is not usually a serious condition. However, treatment is needed if you want to make the eye more comfortable. In a very few people the blepharitis can be severe and damage the eyelids, and treatment can prevent more damage occurring.

The treatment is aimed at

  1. unblocking the glands in the eyelid, which may be infected and inflamed, like acne on the face or a tiny boil by Lid Cleaning
  2. replacing the tears if the eyes are dry with Lubricants (dry eyes and blepharitis may occur together: see below).
  3. treating any infection present with Antibiotic Cream antibiotic cream
  4. omega 3's... the long chain type that are in oily fish, are very helpful and important. Omega 7 as in See Buckthorn oil may help
  5. to treat infection and reduce the inflammation using Antibiotic tablets
  6. steroid creams (only to be used by ophthalmologists/expert professionals)
  7. if possible  reduce doses of drugs likely to contribute to sore eyes, although this is often not possible as they are often essential. Proton pump inhibitors often contribute and their dose can often be reduced.
  8. Blephamask (see Altacor)..some people find these heated masks very helpful.
  9. Tea Tree Oil.  Dilute it and use once daily as the cleaning solution. There may be in infection of the eyelid with an invisible mite demodex. It is likely this is killed by ointments such as VitApos. But diluted Tea Tree oil is also helps many people, and is worth  try, but there is no magic cure. Even with treatment your eyes may remain a little sore, but no harm will come to them and there is nothing to worry about.  See
  10. Alternatively cliradex  helps but is very expensive, and probably no better
  11. Decontaminate skin with iodine or hibiscrub
  12. ?take samples from lids or chalazion to look for demodex

Start with lid cleaning, use antibiotic cream if this is not helpful. Tablets are for people with very troublesome sore eyes.


1 Lid Cleaning

Professor Dua

  1. use a cotton bud and clean margin with baby shampoo
  2. use a hot compress (hand towel, like in an Indian restaurant) soaked in hot water and bathe lid for a few minutes
  3. rub antibiotic into margins for more severe cases (Polyfax, chloramphenicol, or Fucithalmic or azithromycin)
  4. Doxycycline 100mg a day for 1 month, then 50mg a day. Side (sunburns easily), stomach problems, drug interaction, not suitable for children/pregnancy

2 Lubricants

tear drops for blepharitis

drops are needed for comfort

Lubricants can helpful to both assist the spread of your own tears and lubricate the eye, and replace tears if you have 'dry eyes'.

These products are harmless: try and see if they help. You can buy them, but if you need them regularly they can be obtained on prescription. All patients should be tested for dry eyes, generally with a schirmers test.


3 Antibiotic Cream

antibiotic cream such as chloramphenicol may help blepharitis

antibiotic cream such as chloramphenicol may help blepharitis

If the cleaning is not helpful, in addition your eyes may feel more comfortable if you use antibiotic ointment.

4 Diet and fish and flaxseed oil

Diet has a significant effect on the ocular surface.


5 Antibiotic tablets

severe blepharitis..oxytetracycline may help

antibiotic tablets, e.g. doxycycline

This treatment is sometimes useful if the other treatments do not work. It is particularly effective if you have a skin condition, such as acne rosacea, or very dry skin, or if the edge of your eyelid stays red with many scales.

Antibiotic tablets are NOT suitable for everyone, particularly if you use several other tablets, are pregnant/breast feeding, or have stomach problems. You will need to discuss this treatment with your GP first. Doxycycline 100mg once daily [or erythromycin] once daily for one month, then 50mg once daily for 2 more months. Professionals. see.    An alternative: erythromycin dose 250/400 4 times  a day (lower dose after 4 weeks?).

Azithromycin tablets can help, a very short course.

The benefit lasts several months after the treatment is stopped, but you may need to use further courses if the condition returns.


6 Steroid creams etc

Steroid creams can be very helpful, but can be harmful.

Vicious circle of dry eye and blepharitis

see   article




Eye lid Scarring

Severe or persistent blepharitis can occasionally lead to scarring of the eyelid. This leads to lashes growing in towards the eye, which they may rub.

The lashes need to be removed, and there are other treatments if they are a frequent problem. Antibiotic tablets may help to eliminate the blepharitis.


trichiasis: ingrowing lashes
trichiasis: ingrowing lashes








If the eyelids become scarred eyelashes may start to grow in and irritate the eye; they will need to be removed every now and again.


Some causes of blepharitis & sore eyes

Leaflet download

leaflet explaining blepharitis treatment

If you are a health professional and want to have a leaflet to give to give to patients, instead of this web page, see (now out of date) 400k Adobe PDF

Alternatively, this is a Microsoft Publisher (updated 2006) document click here, and you are welcome to download it and print copies. You are welcome to make changes for your patients (you can edit the leaflet in Microsoft Publisher).

You will need M Publisher 2000 to open and print the document. M Publisher is bundled as part of Microsoft Office. The only condition is that you let me know if there are any errors.
The document can be printed out and photocopied to provide a double-sided leaflet 1/3 A4 size for your patients. The address is


Blepharoconjunctivitis in children


mixed (mainly anterior) blepharitis

This is a type of chronic conjunctivitis in children. Essentially conjunctivitis develops but does not get better with treatment, and there is also a blepharitis.

Treatment for children (after Tuft 2015)


Blepharitis anterior & posterior


anterior blepharitisanterior

posterior blepharitis








If the eyelids become scarred eyelashes may start to grow in and irritate the eye; they will need to be removed every now and again.

Gland orifices pout, eyelid margin is hyperaemic, with telangiectasia and clogged up glands, which may ulcerate, and there may be skin flakes ('dandruff'). Chronic blepharitis may lead to trichiasis and marginal keratitis and peripheral corneal neovascularisation.


Meibomian glands

Glands can be

secretions can be graded

Secretions can be examined by gently expressing the glands with a cotton bud, similar to cleaning as above. The secretions shown here are generally sterile.