Good Hope, Heartlands, and Solihull Eye Clinics

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.

Blepharo-keratoconjunctivitis (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


Demodex is the name given to a dust mite that may 'live' in the eyelids. It 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  2018


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 (see treatment for children below)


An excellent review Eye 20.

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.

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

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. Lid bathing: Eyebag, Blephamask (see Altacor) or Meibopatch.  (Meibopatch available on prescription). Some people find these heated masks very helpful, use for 5 minutes twice daily.
  3. Blepharoclean wipes to clean the lids...follow instructions on  the packet
  4. Replacing the tears if the eyes are dry with Lubricants (dry eyes and blepharitis may occur together: see below).
  5. Treating any infection present with antibiotic Cream.
  6. oily fish may help, but omega 3 supplements don't help
  7. To treat infection and reduce the inflammation using Antibiotic tablets.
  8. Steroid creams or drops (only to be used by ophthalmologists/expert professionals) .
  9. 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.
  10. Smoking will make the condition much worse.
  11. A healthy diet: BMJ 18 Minimally processed food is prefered (vegetables, fruit, nuts, seeds, beans, vegetables, whole grains, plant oils, live yoghurt): avoid ultraprocessed foods rich in refined starch and sugars, and industrial additives such as trans-fats and salt.  Blepharitis is linked to a high cholesterol/lipids. BJO 18, so it is likely lowering cholesterol should be part of the treatment.

More specialist treatment measures include

  1. Alternatively cliradex  helps but is very expensive, and probably no better
  2. Decontaminate skin with iodine or hibiscrub
  3. ?take samples from lids or chalazion to look for demodex
  6. clean the whole body with soap and if necessary a staph aureas decontamination. this is n preoperative routine:
    1. Nasal decolonisation BACTROBAN (Mupirocin 2%) nasal treatment. This is used 3 times daily for 5 days. A small amount, about the size of a match head, is applied to a cotton bud or a gloved finger and then applies to the inside of each nostril (apply to the front part of the nostril). The nostrils should then be closed by pressing the sides of the nose together; this will spread the ointment through the nostrils.
    2. Antibacterial bodywash OCTENISAN body wash. Octenisan body wash should be used in place of other soap/skin washes every day for a shower, bath or wash in the 5 days running up to admission. The hair should be shampooed with it on 2 occasions during this time.

1 Lid bathing & cleaning & massaging


Very brief

  1. Heat compresses and massage twice a day
  2. Blephaclean or blephasol twice a day
  3. Preservative free lubricant
  4. vitaPos night

More details

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'.

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,

4 Diet

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 (keep out of sun if using) [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 drops creams etc

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

An example treatment plan for mild blepharitis

  1. Ask GP if it is possible to stop or reduce dose of omeprazole/lansoprazole, as these reduce tear secretions and make the eyes more sore.
  2. Hyloforte every 1-4 hourly
  3. Occ VitApos night.
  4. Vitamin d (perhaps from a chemist or supermarket).
  5. Lid hygiene..meibopatch (microwavable heated eye pads) bathing.
  6. Clean lids with blepharoclean wipes (or less effective clean water using a cotton wool bud or tissue).
  7. Lots of walking (1-2 hours a day physical exercise helps many conditions), and keep weight down.
  8. No junk food, plenty of oily fish, 7 portions of vegetables a day, e.g. 2 salads a day.
  9. Bloods tests for diabetes and thyroid (FBC, crp, U & Es, Lipids, HbA1c, TSH)


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.



Blepharokeratoconjunctivitis in children

separate page


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. 'Kertitis' is the medical name for disease of the cornea.

Treatment for children (TK for Good Hope 2020)

  1. Often one eye
  2. Clean with wipes, various available for purchase from chemist
  3. Hot bathing with Eyebag or equivalent (material heated to a specific temperature in the microwave)
  4. Lids must be clean..this is very important. It is important to change lid 'flora'.
  5. Azithromycin systemically
    1. twice a day for 3 days of week one,
    2. repeat first week of each month for 3 months
  6. Occasionally azithromycin for lids twice a day for 3 days if there is an infection
  7. Dexamethasone (steroid eye drop) preservative free 4 times a day 3 days then reduce
  8. Corneal scarring will generally need long term
    1. Verkazia 4 times a day (this stings for the first few days) or
    2. Protopic (tacrolimus 0.03%) on lids ...some must go in eye
  9. Preservative free lubricant
  10. Epithelium punctate staining is related to disease activity not dryness, will need some lubricants
  11. If the cornea not scarred should be able to control most of disease with cleaning and heat after initial treatment, without long term steroids/Cyclosporine/Protopic
  12. Average 2y treatment, 12% treatment failure
  13. cornea
    • superficial keratitis
    • leukomas
    • corneal vascularisation
  14. there will be occasional flare ups when a short course of steroid drops will be needed


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.


Rosacea in adults

A simple program for moderate blepharitis in adults