Interrelation between Dry Eye – Blepharitis – Chalazion

Dry eye develops when tear production is limited and the eye environment is not ideal, due to this lack of moisture. Not only does it cause the eyes to dehydrate but it also makes them produce tears of bad quality.

The tear is spread on the cornea and it consists of three layers (inner to outer): mucin (protein), aqueous (water), lipid (oil). 

  1. Mucin (protein) layer (produced in the conjunctiva and significantly thinner in women than in men.)
  2. Aqueous layer
  3. Lipid (oil) layer (produced in the Meibomius gland of the eyelid)

At the edge of the eyelid, the lipid and the aqueous parts of the tear are mixed together in order to lubricate the sensitive surface of the eye, which come in constant contact with the eyelids. 

In the case of blepharitis, the change in quality and quantity of oil available at the edge of the eyelid is quite irregular. Thus, the produced tears lack in oil, not properly lubricating the eye surface. This, in turn, induces the foreign body sensation on the eye surface and causes lacrimation. Oddly, it is common that constant lacrimation signifies dry eye. 

Chalazion is created when the oil produced in the meibomian glands is abnormally viscous, making the glands swollen and inflamed.

What is blepharitis?

Blepharitis is an eyelid inflammation caused by the malfunction of the oil glands inside the eyelids. 

It is often associated with a dermatological condition known as acne rosacea.

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Blepharitis Mechanics

When the eye suffers from blepharitis, the oil that flows at the edge of the eyelid is more viscous than normal. On a molecular level it contains small-chain instead of long-chain fats, commonly known as free fatty assets.

This change in the oil physiology in the eyelid glands results in:

  1. The pores of the glands being blocked.
  2. The oil being accumulated on the verge of the eyelids and on the eyelashes.
  3. Dandruff-like deposits are produced.

The oil nourishes the bacteria of the skin around the eyes, inducing their reproduction rate, causing irritation to the eyes.

What causes blepharitis?

There are two types of Blepharitis:

  1. Anterior blepharitis: It affects the outer part of the eyelid, where the eyelashes connect. The most common bacteria that live in the eyes and that are necessary for the biological balance around our eyelids are staphylococcus and streptococcus. During the peak of blepharitis, they grow excessively.
  2. Posterior blepharitis: It affects the inner eyelid (the moist part of the eyelid that comes in direct contact with the eye) and it develops due to malfunctions of the meibomian glands. Two skin disorders that cause this type of blepharitis are: acne rosacea that leads to redness, skin irritation and hair dandruff (seborrheic dermatitis). Both acne rosacea and blepharitis are usually observed at people with a tendency for oily skin, dandruff and dry eyes. Moreover, they can both come out at an early, infant age in the form of granulation of the eyelids and then remain as a chronic disease for life.

It should also be noted that patients suffering from blepharitis and acne rosacea may experience outbreaks and remissions during the period of a year.

How often does blepharitis occur?

Dealing with blepharitis is not easy, as it may recur even after treatment. People from the Mediterranean and Southern Europe contract blepharitis much more frequently than inhabitants of northern countries. It is quite common for newborns, adolescents and women with hormonal disorders to get blepharitis. External factors such as the environment (e.g. climate, fumes), stress, anxiety and nutrition play a part in the appearance of the condition.

Blepharitis symptoms

Most common symptoms:

  • Eyelid irritation
  • Skin irritation
  • Usually eye redness
  • Foreign body sensation
  • Burning sensation
  • Excessive tearing
  • Light sensitivity (photophobia)
  • Blurry vision
  • Foamy tears
  • Dry eyelashes at wake

How is blepharitis diagnosed?

The basic symptoms for the diagnosis of blepharitis are:

  1. Flakes on the eyelashes and on the inflated glands
  2. Staphylococcus contamination that causes ulcer at the pores of the eyelashes
  3. The coexistence of acne rosacea 

How is blepharitis treated?

Blepharitis is a condition that may never be treated but once the irritating symptoms appear, it can be put under control.

The most practical and effective treatment includes the following steps:

 

  1. Application of a heating pad using a clean face towel (not necessarily a sterilized gauze) soaked in salted water (1 tsp. of salt for 1 lt. of water) or in saline solution. Squeeze the towel and place it in the microwave for 1-1.5 minutes until it is hot enough (caution to avoid any burns). Apply it on closed eyelids for 3-5 minutes. Repeat the procedure once or twice. It is advisable to avoid any rubbing of the eyes and the eyelashes to avoid irritation.The aim of this treatment is to transmit heat to the eyelids and alleviate the patient from blepharitis. 
  2. Replacement of bad quality tears with artificial tears. The latter usually contain preservatives to prevent an infection while they are being used. There are also over-the-counter (OTC) tears without preservatives that improve the condition. We suggest using the ones that come in single-use ampoules. It should be noted that to reduce the symptoms of blepharitis the use of artificial tears should be continuous.
  3. Prescription of an antibiotic cortisone ointment. The ointment is applied at the base of the eyelashes, usually before going to bed, using either the finger edge or a cotton pad after proper hand wash. The combination of antibiotics with cortisone serves two purposes. First, to eliminate staphylococcus and streptococcus, which had both spread due to the condition. Second, to limit the inflammation caused to the eyelids due to the cortisone intake. The use of the ointment should not exceed 10 days in a row and 3 weeks in total during one year. The doctor should be informed of the ointment use.
  4.  Topic cyclosporine. When artificial tears do not treat the symptoms (blurry vision, fluctuations, pain), the use of topic cyclosporine is advised for at least two months, and then in the long-term in order to increase tear production. Tear glands are imbued in cyclosporine, reducing the lymph cells within and renewing the natural tear production.
  5.  To treat blepharitis and acne rosacea, tetracycline oral antibiotics are prescribed. The aim of this prescription is to benefit from a side effect of the antibiotics; they are metabolized and emitted from the oil glands resulting in thinner discharges. In most cases, the patients themselves can judge if the treatment is effective as the acne rosacea symptoms and the redness of the edges of the eyelids begin to deteriorate. It is important to note that this treatment is only successful if applied long term; it may need to be repeated several times within a year. Contraindications for the use of this medicine include pregnancy because it may obstruct the teeth and bone development of the embryo.
  6. Proper nutrition can treat blepharitis and acne rosacea. Avoiding fatty foods, spices and excessive alcohol consumption (beer and wine) helps significantly.
  7. Lipiflow. A device that performs thermic massage on the eyelids and expels their oily content for 4-6 months. It successfully replaces a treatment that takes months with a  fewminutes process and the use of medication is avoided.
  8. IPL (Intense Pulsed Light). Our team is a global leader in the application of skin around the eyelids for substantial reduction of blepharitis and acne rosacea. IPL (Intense Pulsed Light).

What is Dry Eye Syndrome?

Under normal conditions, tears are produced at a constant rate. Irritation from a foreign body results in excessive tear production. Dry eye is when the tears are not produced with a constant rate or when they are not of concise quality, thus evaporating quickly. Other factors contributing to dry eye are: keratoconjunctivitis sicca (KCS), dysfunctional tear syndrome, lacrimal keratoconjunctivitis, eustachian tube dysfunction (ETD), aqueous tear deficiency (ATD) and neurotrophic epitheliopathy after LASIK (LNE).

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The lacrimal layer

When we blink, a tear film spreads over the eye, making the surface smooth and clear. The tear film consists of three distinct layers: the mucin (protein), the aqueous (water) and the lipid (oil). Each layer is needed for the tear film to keep our eyes moist. 

  1. The mucin layer contains mucus produced in the conjunctiva. This mucus allows the aqueous layer to cover the eye surface evenly, keeping the eye moist. Without mucus the tears would detach from the eye.
  2. The aqueous layer makes up the largest portion of the tear film. It flows from the lacrimal glands, which are spread in the eyelid diverticulum (usually the upper one) producing tears. This layer washes the eye and it keep away the foreign bodies and other substances that cuase irritation .
  3. The lipid layer is emitted from the Meibomian glands and it is the outer surface of the lacrimal layer. Its purpose is to smoothen the lacrimal shell and reduce tear evaporation.

What can affect the aqueous layer of the eye?

Chronic inflammations of the lacrimal glands increase the concentration of lymph cells, which impede the normal glands function. As a result, tear production may sometimes be non-existent. due to fibrosis.

Dry eye syndrome may be acute or chronic.

What causes dry eye?

Dry eye may be caused by:

  • Side effects of certain medication, including antihistamine, nasal congestion, sedatives, painkillers, diuretics, contraceptives, antidepressants and medicines for blood pressure and Parkinson disease. As these drugs are necessary, the patient may have to tolerate the dryness or use artificial tears
  • Skin conditions of the eyelids or around them
  • Conditions of the Meibomian glands
  • Pregnancy
  • Hormonal therapy in women. Estrogens alone increase the possibility of eye dryness by 70%, while the combination with progesterone by 30%
  • Refractive surgery (LASIK) as a post-operative symptom lasting for 3-6 months or even longer in some cases
  • Eyelid coating Chemical injury or thermal burn
  • Allergies
  • Insufficient blinking after excessive screen use
  • Deficient or excessive vitamin intake
  • Homeopathic medicine, which may intensify ean xisting dry eye condition
  • Corneal sensitivity due to long-term use of contact lenses
  • Immune system deficiencies, such as the Sjögren syndrome, lupus and rheumatoid arthritis

Sjögren syndrome is a chronic autoimmune disease of the connective tissue that mainly affects duct glands. Given that the major carriers for the duct glands are the salivary and the lacrimal glands, the clinical expression of the syndrome is dry mouth and dry eyes. The syndrome is primary when it is manifested by itself and it is secondary when supplemented by other conditions such as rheumatoid arthritis, lupus and scleroderma.

  • Chronic inflammation of the conjunctiva, the membrane covering the eyelid, the front part of the eye and the lacrimal gland.
  • Abnormal exposure of the eyeball, either because of thyroid or because of plastic surgery.
  • Keratitis due to cornea exposure, in case the eyelids don’t close fully during sleep.

What may affect the aqueous layer of the eye?

Chronic inflammations of the lacrimal glands increase the lymph cells concentration, which then affects the operation of the glands. As a result, fibrosis is caused and the tear production is minimum to non-existent.

Dry eye may be a temporary or chronic condition.

How often does dry eye occur?

Tear production is naturally diminished by age. Women are more affected by it more than men.

5,000,000 Americans over the age of 50 years old are believed to suffer from dry eye. More than 3,000,000 are women and more than 1,500,000 are men.

Dry eye usually occurs post menopause. Women who go through menopause early are likely to suffer ocular surface damage due to dry eye.

Dry eye symptoms

  • Burning sensation
  • Itching
  • Foreign body sensation
  • Fibrous mucus in or around the eyes
  • Intense irritation of the eye from smoke or wind
  • The feeling of heavy eyelids
  • Blurry vision
  • Eye fatigue
  • Lacrimation, resulting from eye irritation in its effort to restore its natural moist environment
  • Inability to produce tears during emotional moments
  • Intolerance to contact lenses
  • Difficulty in reading, using a computer and performing any activity that requires constant visual attention
  • Intolerance to dry environments, such as in an airplane
  • Intolerance in eye drop conservatives and artificial drops

How is dry eye diagnosed?

The ophthalmologist makes the diagnosis and prescribes medication. The purpose of treatment is to prevent any permanent damage. In some cases, the diagnosis happens through examinations that measure the tear production:

  • Schirmer’s test includes placing paper strips under the lower eyelids to evaluate the production rate of tears under various conditions.
  • Diagnostic drops (fluorescein or rose Bengal) to detect specific stains

Diagnostic tools involving new technology: 

  • The estimation of the osmolarity in the lacrimal layer using TearLab Osmolarity.
  • Optical coherence tomography (OCT) –cornea epithelial maps
  • Συνεστιακή microscopy

Our scientific team has had the global lead for the use of OCT in epithelial mapping. When necessary, it gives an accurate estimate of the dry eye and the responsiveness to therapy. 

How is dry eye treated?

If dry eye is left without treatment it leads to pain, ulcer or cornea scars. In some extreme cases it may cause vision loss.

How may I help myself?

Limiting tear evaporation rate: 

  • Apply artificial tears, gels and ointments. They temporarily alleviate the symptoms and they replace natural tears in the case of deficiency. Artificial tears should not be used for more than four times per day as they contract the blood cells. Eye itchiness when waking up, which is a symptom of dry eye, can be remedied with ointment application before sleep. It should be noted that this ointment may temporarily cause blurry vision. 
  • Wear glasses or sunglasses with side shields.
  • Use an air purifier to filter dust and other particles in order to prevent dry eye.
  • Use a humidifier to add humidity; in the winter a container with water on top of the radiator can humidify a dry environment.
  • Rest they eyes after long periods of prolonged strain.

Moisturize

  1. Artificial Tears

Over the counter artificial tears moist the eyes. The market offers plenty of options and you may choose whichever suits you best.It is advised to use the ones without preservatives because they are ‘softer’ on the eye and may be used several times within the day.Solid additives of artificial tears may be placed inside the lower eyelids on a daily basis and release substances that increase the moisture within the eye.

2. Plugs Implantation

Another method to keep the eye moist is punctal plugs implantation. This intends to conserve the tears and help artificial tears last longer.

3. When dry eye is caused by the thinning of the aqueous layer, then topic cyclosporine, (commercially known as Restasis) can offer significant rehabilitation. It is the only medication that alleviates dry eye and has long-term results, increasing tear production. After the first 1-2 months of using cyclosporine, the lymph cells of the lacrimal glands are reduced in number and the tear production rate returns to normal.

How to deal with the Sjörgen syndrome?

A review published in the British Journal of Ophthalmology with the title ‘Clinicians with patients who have clinically significant dry eye should be on the alert for underlying Sjögren’s syndrome (SS)’, with a sample of 327 patients showed that artificial tears are the optimal method to treat natural tear deficit. The air humidity in our living conditions should be more than 40%, ideally around 60%, to slow down the dehydration of the ocular surface.

Intense Pulse Light treatment

IPL treatment has been used for years to treat skin conditions such as acne rosacea, μικροαγγειακές face conditions (thread veins), blotches, thin wrinkles (in combination with Botox for deeper wrinkles) and hair removal. Throughout the past years it has been confirmed that patients undergoing these treatments saw significant improvements in dry eye. This has been proven scientifically and bibliographically, making IPL an effective treatment for dry eye syndrome and acne rosacea.

IPL is a therapy using light, slightly more diffused that laser, but of the same technology. Special filters are used to disperse light (in certain wavelengths) into the afflicted blood vessels of the eyelids. These vessels are responsible for the eyelid inflammation and the malfunctioning of the meibomian glands, as well as of the skin. Moreover, the glands absorb the light energy; as a result, thick discharges are liquidated and their flow increases. In general, many patients that suffer from dry eye due to blepharitis and acne rosacea respond well to IPL treatment.

Each skin type calls for different parameters of treatment. During the IPL procedure special glasses are required. A cooling gel is applied on the area of the treatment and it is possible that the patient will experience numbness or a slight burn. After the treatment, pressure is applied on the meibomian glands to aid with the discharge. 

IPL is a painless method that takes about 10-15 minutes to be completed.

Initially, a patient may need to undergo up to 4 sessions (maximum one per month) and then one session per year. It should be noted that the frequency of the treatment depends on the each person’s specific condition.

Many patients follow a treatment regime of once every 3-6 months due to the improvement of the skin, not the dry eye symptoms.

IPL counter-indications

If one of the following indications is in your medical record, please inform your doctor.

  • Skin cancer (e.g. malicious melanoma or non-melanocytic skin cancer or preneoplastic  mutilations, dysplastic nevi)
  • Active skin infection, wound
  • Autoimmune diseases such as Lupus, Ηenoch – Schonlein purpura
  • Herpes Simplex Virus (HSV) infection at the area of the treatment
  • Use of medicines that cause photosensitivity (e.g. isotretinoin, tetracyclines, St. John’s Wort linctus) or cream containing Retinol or Vit A
  • Use of immunosuppressive agents/ immunosuppressive diseases (e.g. HIV)
  • History of non-controlled hormonal/ endocrinological disorders
  • Use of anticoagulant medication or hemorrhagic diathesis
  • History of keloid scarring
  • Sun exposure, solarium, self-tan cream (3-4 weeks before treatment or predicted exposure in the upcoming month)
  • Skin type stage IV (Fitzpatrick)
  • Pregnancy, breastfeeding
  • Epilepsy

Prevention and possible risks

Large radiation intake may cause thermic damage to the skin and lead to hypertrophy, atrophy or hypopigmentation, hyperpigmentation.

Protection with special grasses is necessary during the treatment. If not, the eye may come in direct or indirect contact with the pulsed light, resulting in permanent vision damage; It is prohibited to look straight into the source of light. 

Pre and post-treatment, it is essential to use sunscreen and skin moisturizer. The patient might experience redness and swelling in the hours following the treatment.

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