Eyelid and Eyelid Margin disorders - Optometry Today

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Management Options for UK Optometrists Part 3 

Eyelid and Eyelid Margin 

Disorders 

Course code: C-14374 O/AS/SP/IP 

Professor Michael J. Doughty, PhD 

Eyelid and eyelid margin abnormalities represent some of the commonest 

conditions presenting to optometric and ophthalmological practices. This 

article includes a general consideration of the aetiology and demographics 

of these conditions and patient assessment. The interventions that can be 

undertaken are considered along with the legislation relevant to eyelid 

hygiene products and general-purpose anti-infective agents; consideration is 

also given to product ingredients, indicated uses and follow-up guidelines. A 

brief consideration is also given to the use of topical or oral anti-inflammatory 

drugs by optometrists trained to independent prescriber (IP) level. 

Aetiology of eyelid and eyelid 

margin abnormalities 

Some abnormalities of the eyelids and 

eyelid margin have been studied for over 

a century, 1 have been an obvious cause 

of people seeking attention from medical 

practitioners for over 50 years, 2 and are 

still a likely reason for acute-onset or subacute-onset 

presentations at GP surgeries 

and even A&E; these conditions include 

blepharitis, styes and chalazia. With such a 

historical perspective, one has to conclude 

that none of these conditions have any 

particular cure, nor have we really learnt 

over the years how to effectively manage 

them. Not surprising, therefore, that some 

might still regard blepharitis management 

as “frustrating and challenging”. 3 All 

that has really changed are two things, 

namely that the ‘pharmaceutical’ 

options are considered to be more 

sophisticated and user-friendly, and that 

we now have a better understanding of the 

consequences of inadequate management. 

These conditions, which can be termed 

hordeolae, can also be categorised as 

internal (affecting the main tarsal glands or 

‘Meibomian’ glands) or external (affecting 

the eyelash follicles or the minor glands of 

Zeiss and Moll). In line with some older 

attempts at categorisation, 1 there has been 

a drive in more recent years to try to group 

together various eyelid disease entities, 

with all of these being considered as 

various forms of blepharitis, ie, a condition 

causing inflammation of the eyelids. 3-5 

This is, in part, the classification approach 

used in the College of Optometrists 

Clinical Management Guidelines (CMG). 6 

These would be considered as forms of 

external blepharitis or internal blepharitis, 

although there can also be ‘mixed 

anterior and posterior blepharitis’. 3-5 

The inflammation in itself can be a 

cause of anything from mild discomfort, 

irritation, itchiness, burning sensations 

etc. Blepharitis can be considered as being 

‘sterile’ or associated with an infection 

(see later) and/or associated with a 

variety of skin conditions (seborrhoea, 

atopy, acne, acne rosacea, psoriasis). 

A case can be made that optometric or 

ophthalmological management is unlikely 

to be too concerned about the exact 

location and/or cause of the presenting 

condition, no matter how admirable 

such an endeavour might be from an 

academic perspective, since all treatments 

are essentially designed to improve 

hygiene and reduce inflammation. 3,4,6,7 

The improved hygiene should reduce 

the chance of secondary infection (eg, 

staphylococcal anterior blepharitis) and 

the reduction of inflammation should 

reduce the recurrence and/or ongoing 

development. Adjunct palliative treatments 

include those designed to manage a ‘dry 

eye’ associated with the blepharitis. 

Legislation pertinent to 

management of eyelid and 

eyelid margin abnormalities 

In the UK, entry-level optometrists can 

use current referral guidelines to manage 

and “treat” many aspects of eyelid and/ 

or margin abnormalities, rather than 

needing to refer patients. The perspective 

on management of these conditions, by 

modern-day guidelines, is more one of

preventative care, ie, to reduce the 

chance of presenting acute- or sub-acute 

conditions requiring (from a patient’s 

perspective) urgent intervention. 

For the majority of commonly 

presenting conditions, management 

is with either non-medicinal products 

(CE marked, MD, SL, GSL) or products 

designated as P Medicines. All of these 

can be accessed (including by way of 

wholesale trading), supplied and sold 

on (at recommended retail price) to 

patients by all optometrists, as well 

as being available via the Internet. A 

few conditions may present as severe, 

as they have developed over many 

months prior to their being seen by the 

optometrist, and may respond to these 

types of treatments but really need more 

substantial medical (or even surgical) 

intervention. Notwithstanding, the 

optometrist is in an excellent position to 

either co-manage these conditions with a 

patient’s GP (for access to certain topical 

or oral prescription-only medicines) 

or to facilitate assessment by an 

ophthalmologist at their local hospital. 

Eyelid margin hygiene 

products – options, use and 

patient assessments 

The cause of many common eyelid and 

margin problems is poor ocular hygiene. 

Whereas it was once acceptable to simply 

encourage facial and peri-ocular hygiene 

by use of a face flannel, energetically 

rubbed around and along the eyelids, such 

practices have all too often been resigned 

to history and alternatives introduced 

that focus (sic) on the site of the problem. 

Inspection of the eyelid marginal zone, 

unaided or especially by biomicroscopy, 

will reveal that it is rarely ‘squeaky’ 

clean, but that particulate and/or oily 

debris can be present around the bases 

of the eyelashes and across the orifices 

of the adjacent Meibomian glands. Some 

oily material is normal and the amount 

of ‘meibum’ across the marginal zone 

can be assessed 5,8 using a meibometer 

(not commercially available in UK). 5 This 

narrow oily zone serves as a limiting barrier 

to the edge of the proximal tear meniscus 

(lacrimal lake) so as to stop tears normally 

overflowing across the eyelid margin. 5,9 

Its normal presence and function should 

be a reminder that excessive cleansing 

of the eyelid margin is not beneficial. 

However, excess non-cleansed meibum 

will mix with material that causes eyelid 

margin problems to slowly develop. Even 

for an eyelid that appears to be clean, 

impression cytology (where small filter 

disc is pressed against the eyelid marginal 

zone) can be used to show that this zone 

is covered with dead cells (Figure 1). 

Such cell material and debris, mixed with 

denatured meibum, can accumulate if not 

regularly removed. With each eyeblink, 

this material will likely be compressed 

against the bases of the eyelashes, congeal 

and dry out; the patient now presents 

with an obvious anterior blepharitis. 

Eyelid hygiene for blepharitis is 

important and has long been recognised 

with recommendations for application 

of natural plant extract (eg, chamomile) 

infusions, 1 or lotions of boric acid, 2 and 

these can still be useful in certain cases, 

eg, for seborrhoeic blepharitis. 4 The use of 

sodium bicarbonate solutions also dates 

back at least 50 years, 1 and persist in some 

current day guidelines, 3,6 despite there 

being almost no information available as 

to what constitutes a satisfactory sodium 

bicarbonate solution for wiping the lid 

margins. More aggressive treatments have 

also included cleaning the eyelid margins 

with a 1:5000 solution of benzalkonium 

chloride, 10 noted for its ‘valuable 

detergent action’, or the application of 

a 2% solution of silver nitrate. 11 Where 

the blepharitis is associated with a scalp 

condition (eg, seborrhoeic blepharitis 

with uncomplicated chronic dandruff), 

treatment of the hair and scalp is likely 

an essential part of management (eg, with 

daily use of shampoos containing anti- 

‘mould’/fungus/yeast compounds such 

as selenium sulphide or ketoconazole). 

The ocular use in the 1950’s of 

Selsun ophthalmic ointment (selenium 

sulphide 2.5% with 17% surfactant), 12 

is no longer recommended simply 

because it is too toxic for the delicate 

mucous membrane of the conjunctiva 

The once or twice-daily application 

of ophthalmic ointments containing 3% 

ammoniated mercury, 11 or 1% yellow 

mercuric oxide, 13 have also suffered the 

same fate after regulatory authorities 

decided that the possible adverse effects 

of chronic use of mercurial compounds 

outweighed the potential benefits. 

More recent times have seen the 

introduction of eyelid hygiene products, 

perhaps also more widely known by as 

Figure 1 

Material obtained by impression cytology from 

across the human eyelid margin zone stained with 

rose bengal (in vivo) and with Giemsa (ex vivo) to 

show large and sometimes anucleate squamous 

cells (some of which are stained crimson) 

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‘lid scrubs’, and referred to as ‘dedicated 

cleaning solutions’ by the CMG. 6 A 

limited number of commercial products 

were introduced in North America in 

the 1980’s, and designed to replace the 

home remedy and unlabelled use of a 

proprietary baby shampoo for eyelid 

hygiene. 14 Notwithstanding, the advice 

and recommendations for the use of baby 

shampoo have persisted well beyond 

the commercialisation of ‘lid scrubs’. 4,8,15 

Perhaps rather ironically, baby shampoo 

may be used as the referent treatment for 

evaluation of new products. 15,16 Eyelid 

hygiene products have now become 

increasingly popular, with most finding 

their way into pharmacy product listings 

(eg, Chemist and Druggist Monthly) 

and even some over-the-counter (OTC) 

directories. These products are not 

routinely listed in a MIMS or BNF, 

because they are non-medicinal and, 

at least as yet, not considered true 

treatments for a common condition. 

The contemporary eyelid hygiene 

products are designed to gently cleanaway 

accumulated material, preferably 

before it gets too compacted and dried 

out. The ingredients include a range of 

mild surfactants (detergents) and soothing 

agents (Table 1). The overall formulations, 

drawing on experience with cosmetics, are 

generally designed to be hypoallergenic 

The synthetic surfactants are numerous 

(Table 1) and include a range of anionic 

and/or non-ionic surfactants with (tri) 

glyceride or glycol side chains that should 

help disperse oily materials. 14 Other 

ingredients are partly based on very old 

concepts where certain natural plant 

and flower extracts (eg, Hamamelis) are 

considered to have astringent properties 

as well as being generally soothing. Other 

natural ingredients provide soothing effects 

but may not provide any extra cleansing 

PRODUCT NAME SURFACTANT / 

CLEANSING 

INGREDIENTS 

LID CARE 

(PADS) 

SUPRANETTES 

(PADS) 

BLEPHACLEAN 

(PADS) 

BLEPHASOL 

(SOLUTION) 

STERILID 

(FOAM) 

(sodium) 

lauroamphodiacetate, 

(sodium) trideceth 

sulphate, 

hexylene glycol, propylene 

glycol, PEG-20 sorbitan 

monolaurate, 

PEG, polysorbate 80, citric 

acid 

PEG-8, poloxamer 184, 

polysorbate 20, capryloyl 

glycine, 

propylene glycol 

PEG-8, poloxamer 184, 

polysorbate 20, capryloyl 

glycine, 

propylene glycol, caprylic 

/ capric 

glycerides 

No sPEG-80, sorbitol 

laurate, 

Sodium 

lauroamphoacetate, 

sodium trieth sulphate, 

cocamidopropyl betaine, 

cocamidopropl PGdimonium 

NATURAL 

CLEANSING 

(ASTRINGENT), 

SOOTHING and 

OTHER NATURAL 

INGREDIENTS 

none listed 

Hamamelis 

virginiana extracts, 1 

Calendula 

officianalis 

extracts, 2 

zinc sulphate, 

Centella Asiatica 

extracts, Iris 

florentina extracts, 

retinyl palmitate 

zinc sulphate, 

Centella Asiatica 

extracts, Iris 

florentina extracts, 

retinyl palmitate 

allantoin, linalool 

oils, tea tree oil, 

panthenol 

BUFFERING AGENTS 

STABILIZER 

PRESERVATIVES 

boric acid 

EDTA 

Phosphate 

methyl & propyl 

parabens 3 

phosphate 

phosphate 

boric acid 

EDTA 

sodium 

perborate 4 

Table 1 

Eyelid hygiene products and their ingredients. PEG = polyethylene glycol; 1 also known as witch hazel; 2 also 

known as pot marigold; 3 conventional preservatives; 4 oxidative preservative 

action, eg, Calendula extracts, allantoin, 

or natural oils. There is current interest 

in the (mild) antibacterial effects of fairly 

large amounts or concentrated solutions 

of tea tree oils, 16 or linalool oil mixtures. 17 

The extent of the blepharitis can be 

graded (eg, 0 to 4 scale) and the patient 

reassessed periodically (every few weeks)

to see how well they are managing with lid 

are excreted and so contribute to a normal 

hygiene. Management of blepharitis may 

thickness lipid layer on the tear film. 21 

take many weeks or months to resolve. 

An alternative to warm compresses is the 

The eyelid margin (at least by unaided 

vision or even close-up photography) 

may not appear that different before and 

after routine preventative eyelid hygiene 

measures. 15,18 This is an important point, 

since by current day perspectives one 

should really not be able to see that the 

eyelid margins have been ‘scrubbed’ 

ie, the cleansing, in itself, should not 

redden and inflame the lid margin! 

The way in which ‘lid scrubs’ are used 

is so important for effective management 

of chronic blepharitis, and it is perhaps 

unfortunate that we have to largely rely on 

anecdotal accounts rather than organised 

clinical trials. One needs to consider 

how the ingredients are actually brought 

into contact with the eyelid margin, 

how often the procedure is undertaken 

and how long the treatment should last. 

Eyelid Margin Hygiene Technique 

The technique of eyelid hygiene should 

be selected according to the extent of the 

presenting signs, and a practitioner needs 

to take time to evaluate their patients 

and instruct them on the principles. If 

dominated by a greasy/oily appearance, 

perhaps with ‘foam’ along lateral 

aspects of the eyelid margin (which 

are also indicative of Meibomian gland 

dysfunction – MGD), then logically the 

eyelid margin really only needs to be 

gently wiped with a surfactant mixture to 

facilitate removal of such material. Some 

of these current products are cotton gauze 

pads soaked with the ingredients. These 

Figure 2 

Scanning electron microscopy of an upper eyelid 

margin of a rabbit presenting with mild blepharitis. 

The bases of the eyelashes (top of image) are 

largely obscured by large quantities of compacted 

dead cells and, most notably, the distal edge of this 

‘garbage zone’ is clearly colonised with numerous 

rod-shaped bacteria 

minimum requirements for any special 

manual dexterity, 15 even in children. 19 

Some practical trials on the efficacy of 

lid scrubbing have used six cycles of 

back-and-forth rubbing, 16 or even ten 

cycles. 20 However, a few wipes approach 

can likely be continued for as long as 

a problem is apparent. If oily/greasy 

material predominates and there are just 

some slight signs of MGD, then promoting 

normal meibum excretion onto the eyelid 

marginal zone might be achieved with the 

daily use of warm (wet) compresses. This 

also is a time honoured remedy, 10 but likely 

needs to be applied for several minutes to 

be effective, eg, 5 to 10 minutes of warm 

compress with a cotton ball, gauze pads 

or even the clean facial flannel, which is 

a little above normal body temperature; 

repeated re-warming of the material is 

thus essential (eg, by re-dipping into a 

bowl of moderately warm water). Recent 

similarly long duration (10 to 15 minute) 

use of a heated eye mask or eye bag. 22 

If the oily detritus appears a little more 

resistant to the wiping action of a gauze 

pad, then there are liquid products that 

can be used instead. These can be applied 

onto separate cotton gauze pads and 

used in the same way as described or 

can be transferred to a sterile cotton bud 

applicator. The pre-packed individual 

sachets, once opened, may have enough 

liquid associated with the pad to 

adequately wet a cotton bud, which can 

then be systematically worked along the 

eyelid margin and bases of the eyelashes 

with gentle pressure. It will be up to the 

individual whether this is a rubbing back 

and forth action or simply one in which 

the cotton bud is slowly moved fairly 

firmly along the lid margin allowing for the 

solution to soak into the skin and eyelash 

bases. After a minute or so, a gauze pad can 

then be used to wipe away the dispersed 

material. One of the newer products 

comes in the form of a dispenser and the 

emergent foam is to be applied along the 

eyelid margin with the fingers, with the 

patient being advised that good hand 

hygiene with a non-irritating soap product 

is an essential part of such a procedure. 

According to the severity of the 

presenting condition, cleansing can be 

done once a day (eg, before retiring to bed) 

or twice-a-day (morning and night), with 

the patient advised that regular gentle 

cleansing is likely the most effective way 

37 

17/09/10 CET 

are designed to be simply wiped back-and- 

research has established that not only 

of achieving a good result and to avoid too 

forth along the outer edge of the eyelid 

does the temperature need to be slightly 

aggressive ‘scrubbing’. Patients were once 

margin, with the procedure perhaps being 

higher than normal body temperature 

advised to undertake the procedure before 

repeated two or three times before the 

(ie, at 40 o C to 45 o C), but that this can 

retiring to bed ‘in order that the erythema 

pad is discarded. This can be done with 

improve the amount of normal oils that 

produced can subside during the night’. 12


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The inclusion of soothing agents in 

contemporary products hopefully 

serves to emphasise that lid hygiene is 

not meant to be a traumatic procedure. 3 

Similarly, too aggressive ‘scrubbing’ (eg, 

excess warm/hot compresses, excess 

application of cleansing pads or even 

Meibomian gland expression) can lead to 

at least temporary focal loss of eyelashes; 2 

this is hopefully avoidable. There is no 

efficacy data as to why the eyelid hygiene 

should be done before retiring to bed, and 

one could likely find equal arguments as 

to whether female patients would prefer 

to undertake eyelid hygiene at the same 

time as removal of facial cosmetics or 

as a separate activity in the morning 

(prior to application of cosmetics). 

The issue of cosmetics use and the 

development of ‘blepharitis’ remains 

unclear, despite sporadic attention to 

the issue over the years. 23 A patient may 

present with mascara forming a liberal 

coating over a few or several Meibomian 

orifices, yet it is entirely possible that this 

will be removed as a result of effective 

use of surfactant-containing make up 

remover. However, for some patients, 

the efficacy of their cosmetics removal 

may need to be reviewed. A male patient 

might be expected to carry out lid hygiene 

Figure 3 

Clinical presentation of a likely infection of a eyelash 

follicle or accessory sebaceous gland associated 

with the eyelashes (a ‘stye’) 

prior to a fresh start in the morning with a 

shave etc., which might produce a more 

useful result in the long-term management. 

The consequences of poor 

eyelid hygiene - the eyelashes 

and associated glands and its 

management 

If eyelid and peri-ocular hygiene is poor, 

then one can expect a progressive buildup 

of dead cells and meibum along the 

eyelid marginal zone. Electron microscopy 

studies on laboratory animals with 

obvious signs of blepharitis (Figure 2) 

show how substantial this material can 

be. 24 An almost inevitable consequence 

is colonisation of the eyelid margin zone 

with substantial numbers of bacteria. 

Most commonly this will result in a 

staphylococcal blepharitis, 1,12 since S. 

Aureus or S. epidermidis are common 

rod-shaped bacilli found on the normal 

lid margin. Other bacteria can also cause 

an infectious blepharitis, 11 notably those 

associated with acne-like conditions 

(eg, Propionobacterium acnes). 3,4 

For such infective blepharitis, a slightly 

more aggressive approach is likely needed 

for eyelid hygiene. The blepharitis, likely 

to now be of a recurrent and chronic 

nature, presents with signs of drying of the 

cellular and oily detritus, notably forming 

collarettes around the eyelash bases, or 

‘skuff’ that even extends quite a way 

along the eyelashes. This material needs 

to be moistened and softened before it can 

then be gently removed. Whether using 

a gauze pad or especially a cotton bud 

applicator, the idea should be to ‘daub’ 

the eyelid margin with the cleansing 

agent and leave it for a few minutes. 2,4 In 

uncommon cases, the personal hygiene 

of a patient is likely to be so poor that the 

eyelashes (as well as other hair follicles) 

can become colonised with lice or 

mites, 3 eg, Demodex sp. 16 Any collarettes 

that appear to be particularly resistant to 

softening and wiping should be examined 

more carefully (eg, with biomicroscopy) 

for any signs of ‘macro’-organisms. 

When eyelid and personal hygiene is 

poor, another inevitable consequence is the 

development of a focal infection of either 

an eyelash follicle or accessory glands of 

the eyelashes. This results in an acute-onset 

focal swelling, a stye (Figure 3). These can 

be quite painful and result in swelling of the 

entire eyelid so that it presents closed. The 

key to successful management is to get the 

infection site to ‘point’ and the pus contents 

to be released so as to relieve the discomfort. 

By current perspectives, this is best done 

with the application of a warm compress 

(for 10 to 15 minutes) over the affected 

region, followed by carefully wiping and 

cleansing with clean soft cotton or an eyelid 

hygiene pad. The procedure should be 

repeated a few hours later until resolution, 

with it being emphasised to the patient that 

keeping the area clean is important. Patients 

should also be advised that it is not generally 

a good idea for them to attempt to forcibly 

puncture the stye with a sharp object 

(although this might be done in extreme 

cases, under suitably clean conditions with 

a sterile lance by a health care professional). 

Home remedies such as using a sharpended 

cocktail stick or toothpick, dipped 

in phenol, 2 are no longer appropriate. 

When a stye develops, or is in the 

process of being pointed, the personal 

hygiene may be supplemented with the 

use of a topical anti-bacterial agent applied 

after the eyelid cleansing procedure. 

The ideal agent currently available are 

preparations containing diamidines, 

notably dibromopropamidine; Golden 

Eye Ointment and Brolene Eye Ointment 

are both available in small 5g tubes as P 

Medicines. These chemical anti-infectives

work to reduce the replication of common 

of the eyelid margin outwards and exert 

bacteria that affect the eyelid margin, 

sufficient pressure to expel the contents 

ie, they are bacteriostatic. 25 Twice daily 

of the glands in that region. 27,28 The 

application of the ointment along and 

digital pressure may need to be exerted 

across the eyelid margins where the stye(s) 

for 30 seconds or more. A patient can 

is present should reduce the chance of 

be carefully instructed to do the same. 

cross infection of adjacent eyelashes. For 

most cases, the use of an antibiotic is not 

considered necessary, although some 

may opt for the use of chloramphenicol 

eye ointment, 6 or fusidic acid viscous 

eyedrops; 26 the use of fusidic acid might 

be considered as an acceptable but 

‘unlabeled’ use. 6 Both antibiotics are 

available as POMs (eg, Chloromycetin 

Eye Ointment and Fucithalmic) and the 

former is also now widely available as 

P Medicines (eg, Optrex Infected Eyes 

antibiotic drops, GoldenEye antibiotic 

ointment and Brochlor antibiotic 

ointment). All these anti-infective and 

antibiotic preparations are available to 

entry-level and AS level optometrists. 

The combined consequences 

of poor eyelid hygiene and 

an inflammatory response – 

Meibomian gland dysfunction 

and its management 

The normal organisation and functioning 

of the Meibomian glands involves a 

holcrine secretory mechanism whereby 

the fatty contents of the glands undergo 

a transition to an oily fluid which is then 

expressed out of a patent orifice with 

every eyeblink. The orifices are lined 

with a stratified epithelium that can show 

various degrees of keratinisation. 3-5 If 

eyelid hygiene is poor, then the orifices 

can become blocked with dead cells and 

a slow progressive process of stenosis 

develops. The glandular orifices can 

lose their characteristic ring-shaped 

appearance to be replaced by small domes 

Figure 4 

Clinical presentation of an individual with moderate 

plugging of the Meibomian gland orifices. The 

lissamine green (and NaFl) staining reveals 

irregularity of Marx’s line but it is still located 

posteriorly to the Meibomian gland orifices. 

respects, be considered to look like small 

styes, they are usually posteriorly located 

to the eyelashes. Plugged orifices usually 

cause little discomfort and are unlikely 

to be infected (unless there is substantial 

concurrent infectious anterior blepharitis). 

Such plugged orifices, even at early 

stages, cannot normally function to 

express the oils onto the eyelid margin, 

and so the patient may well present with 

symptomology suggestive of tear film 

deficiency, ie, dryness, scratchiness of 

the eyes, simply because the tear film is 

unstable. For early stage presentations, 

simply restoring normal glandular 

secretion should be the goal. The routine of 

regular eyelid hygiene is appropriate, with 

the combined effect of cleaning and gentle 

rubbing or massage of the eyelid margins 

adequate to restore patency to the glands. 

A practitioner may elect to carefully 

assess whether a gland orifice is actually 

patent by applying pressure in the vicinity 

of the blocked orifices. In line with the 

perspective that eyelid hygiene is not meant 

to be painful or traumatic, an appropriate 

approach would be to gently position the 

affected part of the eyelid margin between 

thumb and forefinger and exert a gentle 

If assessed at the slit lamp, the 

appearance of clear (serous-like) or slightly 

cloudy (milky) liquid droplets indicates 

the orifice, whilst temporarily blocked, is 

at the end of a functioning gland. One can 

attempt to do this along the length of the 

eyelid margin, noting that it is often rather 

more difficult to carry out towards the 

canthi and along the upper eyelid margin. 

If no exudate appears, the orifice is more 

substantially blocked, even keratinised. 

A practitioner can effect a little more 

focal pressure by attempting to squeeze 

the edge of the eyelid margin between 

either a clean cotton bud applicator tip 

and a forefinger, or between two cotton 

bud applicators; fluid droplets or more 

compacted (inspissated) contents are 

extruded. 8 In extreme cases, the pressure 

needed to express a gland requires a 

force to be applied against a hard object 

such as a metal spatula tip, 1 and the 

extruded contents may appear to have the 

consistency of toothpaste and be opaque; a 

topical ocular anaesthetic should really be 

considered if such force is to be applied. 

Overall, however, in routine practice, such 

overzealous attempts to express the glands 

are likely to be most uncomfortable for the 

patient, 29 and it is likely better to adopt a 

slow and steady approach over many weeks 

with routine use of warm compresses 

and eyelid hygiene. The efficacy of all 

such measures can also be assessed by 

transillumination of the eyelid margin 

to assess whether a gland has its normal 

elongated and uniform density or whether 

its contents are segmented, indicative of 

39 

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(Figure 4). While these may, in some 

pinching motion to both direct the portion 

severe compaction of the contents. 3-5,28,30


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The consequences of not restoring 

or in others the apparent tear stability (as 

routine function of the Meibomian glands 

fluorescein tear break-up time measures) 

is now better understood and more easily 

may be normal, 38 even in acne rosacea. 

visualised (Figures 4 versus 5). Figure 

In some blepharitis cases (eg, atopic 

5 shows the upper eyelid margin of a 

eyelid disease/blepharitis with or 

40 

patient with a chronic history of recurrent 

staphylococcal blepharitis evident as 

collarettes along the eyelash bases and 

without MGD), patient symptoms may 

be exacerbated by high temperatures or 

intake of hot spicy foods (both causing an 

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chronic blockage (‘fall out’) of functioning 

Meibomian gland orifices. The locations of 

the more anterior portions of the glands are 

evident as blotchy white regions that may 

or may not conceal partially functioning 

orifices. However, what is especially 

notable is the green staining line revealed 

with lissamine green that is clearly located 

anteriorly to the orifice regions; this is the 

anterior location of Marx’s line and with 

Figure 5 

Clinical presentation of an individual with moderate 

anterior blepharitis with almost complete 

obliteration of the Meibomian gland orifices. 

The lissamine green staining not only reveals 

irregularity of Marx’s line but it is now partially 

located anteriorly to the Meibomian gland orifices. 

From Doughty MJ et al. (2004) Ophthalmic Physiol. 

Opt. 24: 1-7. Copyright The College of Optometrists 

associated sweating). 4 For such patients, a 

little eyelid cleansing with lid wipes may 

serve to effectively augment routine facial 

hygiene and reduce symptoms. Associated 

reflex tearing may give rise to high values 

for tear secretion/volume assessments 

(Schirmer/tear meniscus height; see 

Optometry Today, August 13 2010). 35 

If staining and tear instability is apparent 

(eg, in seborrhoeic blepharitis), then the 

this configuration it has been argued that it 

especially if the patient is symptomatic. 

patient will likely benefit from the judicious 

is most unlikely that any gland secretions 

Similarly, for an older patient being 

use of artificial tears, 4,6 and should be given 

will be able to serve a useful function. 9 This 

considered for cataract surgery, reduction 

instructions to use these just as if they had 

is because the oils will now be secreted 

or elimination of infectious blepharitis 

dry eye (see Optometry Today, August 13 

into the aqueous layer of the tear film rather 

than be extruded across the surface of the 

aqueous layer. In contrast, the lissamine 

green staining line in Figure 4, whilst 

somewhat irregular in width, is posteriorly 

located so that a functional secretion of the 

meibum can still occur. The same feature 

may be considered very beneficial. 3 

Some patients with chronic MGD, 

perhaps particularly those with acne 

rosacea, may show substantial signs 

of tear film deficiency as evidenced 

by rose bengal staining. In some cases 

of blepharitis, warm compress and lid 

2010). However, if staining is not evident 

then symptomatic relief may be provided 

with a comfort drop or moisturiser. This 

distinction could be important for a 

patient, since it has long been noted that 

patients with blepharitis may particularly 

experience symptoms ‘during the use of 

will also likely stain with rose bengal. 31 

For the optometrist considering 

hygiene measures can reduce staining 

and improve tear stability, 34-36 but various 

near vision under artificial illumination’. 11 

The modern-day equivalent could be the 

management of more severe cases of 

studies indicate that one should not 

computer user with obstinate blepharitis. 

Meibomian gland problems, whatever its 

expect to see any obvious (short-term?) 

In non-infectious blepharitis, for largely 

aetiology, consideration needs to be given 

improvement in the appearance of the 

unknown reasons, the non-extruded gland 

to the assessments that need to be made. 

Meibomian gland orifices. It needs to be 

contents elicit a progressive inflammatory 

The optometrist also needs to decide when 

remembered that shortly after any eyelid 

response from inside the glands. In cases 

they really should rise to the challenge 

of dealing with blepharatis. For example, 

if observed in a contact lens wearer it is 

likely to be associated with other problems 

such as excessive spoilage of the lens. 32,33 

The continuing presence of the lens may 

hygiene that promotes Meibomian gland 

expression, tear film findings may be 

equivocal. 27 It is also possible that at some 

point in time (up to a few hours?) shortly 

after lid hygiene measures, there may be a 

more frothy discharge (‘foam’), especially 

of infectious blepharitis, it has been argued 

that enzymes (phospholipases) produced by 

the bacteria can alter the characteristics of 

the meibum to exacerbate this inflammatory 

reaction. One well-known consequence of 

this is the emergence of a focal inflammation 

actually exacerbate build-up of meibum 

and detritus along the lid margin. 29 The 

blepharitis really needs to be managed, 

if patients have been rubbing their eyes. 37 

In other cases, neither surface staining 

nor tear film instability may be apparent, 

of a Meibomian gland, a posterior/interior 

hordeolum or chalazion (Figure 6). 

As long as the gland orifice is blocked

and the production of meibum continues, 

the associated inflammation can result in 

single or multiple lumps along the eyelid 

margin. There is no immediate remedy 

but the application of warm compresses 

for 10 to 15 minutes several times a day 

will usually help to remedy the situation. 

This allows for a slow but progressive 

restoration of the gland, and the swelling 

subsides. Application of gentle pressure 

and massage may assist this, but at this 

stage firm digital or other pressure to try 

to promote expression is only likely to 

lead to extreme discomfort. Routine eyelid 

hygiene remains important as a means 

of preventing any focal infection. Older 

remedies have included instructing the 

patient to apply an ophthalmic antibiotic 

ointment along the eyelid margins two to 

three times a day and then massage it in, 12 

but are no longer thought to be of significant 

benefit (but see below). If the chalazion fails 

to respond to external compresses and the 

contents really harden, then the patient will 

need to be referred to an ophthalmologist 

to have the chalazion excised. 39 

Special issues in the management of MGD 

Certain adjunct treatments can be 

beneficial, one of which is likely more 

appealing and available to the entry-level 

optometrist and the other accessible for 

the IP-trained optometrist. By current 

ideas, chronic MGD is thought to reflect 

an imbalance between certain types of 

essential fatty acids in the body, with 

omega-3 compounds likely the most 

common. 4,5 There has, therefore, emerged 

an idea that supplementing a patient’s 

normal oral intake of omega-3 fatty acids 

(eg, flaxseed oils) may improve MGD. 4 

While rather hard to prove, evidence has 

been presented that the consistency of 

expressed meibum can improve following 

use of such supplements, 13 along with 

Figure 6 

Clinical presentation of an individual with a 

recurrent history of Meibomian gland dysfunction 

where the compaction and inflammation of the 

glandular contents leads to swelling (a chalazion) 

improvements in tear film quality. Longterm 

studies still need to be done to 

ascertain whether there is a sustained 

improvement as well as reduction in 

recurrence of MGD. Notwithstanding, such 

supplements are now widely available as 

GSL or non-medicinal products, including 

over the Internet, and so available to entrylevel 

optometrists and patients alike. 

The second approach is to use orally 

administered antibiotics that have 

anti-inflammatory actions. These are 

the tetracycline group of antibiotics 

eg, chlortetracycline. It was once a 

recommended practice to ask a patient with 

blepharitis to apply chlortetracycline eye 

ointment (Aureomycin) two to three times 

per day, and this should be continued for 

a month before perhaps being reduced to 

one to two times per week over the ensuing 

months. 12 While no longer formally 

marketed, some NHS trusts may still 

list and produce an equivalent (generic) 

product which might be accessed by an 

IP optometrist or a hospital optometrist 

working under a patient group directive. 

Orally administered tetracyclines such 

as minocycline (not to be confused with 

other oral macrolide antibiotics such 

as erythromycin) can also be used in 

patients with recurrent MGD associated 

with conditions such as acne rosacea. 25 

Current College of Optometrists CMG, 6 

indicate that it could be appropriate 

for an IP optometrist to be involved in 

the prescribing of the relevant PoMs. 

While the exact mechanisms whereby 

this might be realised for the optometrist 

are still to be resolved, the option of comanagement 

and asking a patient’s GP 

to provide the prescription would be 

appropriate, eg, Minocin MR at 2 x 100 

mg BDS for three months; one ought to 

consider, however, the risk of substantial 

gastrointestinal side effects. 3,34,35 Lower 

dosing (eg, 20 mg BDS) may be efficacious 

as a maintenance dose but it is unclear 

whether such an intervention would be 

adequate to reduce the severity; the use of 

lower doses should however reduce the 

risk of adverse reactions. Ocular rosacea 

may also be managed with judicious 

(unlabelled) use of a topical gel (for the 

skin) containing another antibacterial 

drug, metronidazole (PoM Rozex). 40 

Conclusion 

With eyelid and eyelid margin 

abnormalities being rather common 

conditions, optometrists are well placed 

to manage them. The most important 

aspect of this management relates to 

educating patients on ocular hygiene, 

but advice on palliative measures 

and the adjunct use of anti-infectives 

or antibiotics is appropriate as well. 

About the Author 

Professor Doughty has been teaching ocular 

pharmacology, as well as many aspects of 

ocular physiology and eye disease, for over 

25 years and authored books on the subject. 

He has held the post of research professor 

at Glasgow Caledonian University, 

Department of Vision Sciences since 1995. 

References 

See www.optometry.co.uk and search 

‘references’ 

41 

17/09/10 CET


EDUCATION 

& TRAINING 



4 4 4 4 


Module questions 

Course code: C-14374 O/AS/SP/IP 

42 

17/09/10 CET 

1. Structures involved in the development of blepharitis include which of 

the following: 

(a) The eyelashes 

(b) The glands of Zeiss 

(c) Meibomian glands 

(d) All of the above 

2. Which of the following statements about eyelid cleansing and hygiene 

products is TRUE? 

(a) They are non-medicinal products 

(b) They are marketed as cosmetics 

(c) They will not be sold as medical devices 

(d) They are usually designated as P Medicines 

3. Past treatment options for blepharitis have included which of the 

following? 

(a) Regular applications of chlortetracycline ointments along the lid margins 

(b) Wiping the eyelid margin with benzalkonium chloride solutions 

(c) Application of phenol solutions to affected parts of the eyelids 


4. Which of the following statements about modern-day treatment of 

non-infectious chronic blepharitis is TRUE? 

(a) It should routinely include the use of antibiotic eye ointments 

(b) It can be effectively achieved with regular use of dedicated cleaning solutions 

(c) It always needs to be supplemented with oral antibiotic and antiinflammatory 

drugs 

(d) It can likely be achieved with just the use of warm compresses or eye pads 

(masks) 

7. Which of the following statements about current perspectives for 

routine eyelid hygiene using a cleaning pad or cotton bud is TRUE? 

(a) It needs to be gently rubbed back and forth a few times 

(b) It should simply be wiped once along the eyelid margin and then discarded 

(c) It needs to be repeatedly used in a scrubbing motion along the eyelids many 

times 

(d) It is only really needed if there are signs of infection present 

8. Which of the following is an expected consequence of chronic 

Meibomian gland dysfunction? 

(a) Development of collarettes around the eyelash bases 

(b) Oily excretions from the Meibomian glands 

(c) Focal loss of eyelashes 

(d) Development of single or multiple internal hordeola 

9. For a suspected case of staphylococcal blepharitis, which of the 

following products would be MOST appropriate after eyelid hygiene 

measures? 

(a) Oral Minocin MR (PoM) 

(b) Brolene Eye Ointment (P Medicine) 

(c) Aureomycin eye ointment (PoM) 

(d) Blephasol solution (SL) 

10. Eyelid transillumination is a procedure that might be used for what 

purpose? 

(a) Assessment of the extent of inspissation of the Meibomian glands 

(b) Checking to see if the eyelash follicles are intact 

(c) To assess the location (anterior or posterior) of Marx’s line 

(d) None of the above 

5. Which of the following is an example of a surfactant cleansing agent in 

an eyelid hygiene product? 

(a) Chamomile 

(b) Boric acid 

(c) Polysorbate 

(d) Sodium bicarbonate 

6. Which if the following can be considered as soothing agents included 

in contemporary eyelid hygiene products? 

(a) Boric acid 

(b) Calendula extracts 

(c) Lauroamphocetate extracts 

(d) Phosphate salts (buffer) 

11. Which of the following antibiotics can be useful as part of the 

management of some cases of blepharitis? 

(a) Chloramphenicol 

(b) Minocycline 

(c) Fusidic acid 


12. Which eyelid feature should be more carefully examined by 

biomicroscopy if lice were the suspected cause of the blepharitis? 

(a) The outer canthus 

(b) The bases of the eyelashes 

(c) The shafts and tips of the eyelashes 

(d) The Meibomian gland orifices 

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on October 20 2010 - You will be unable to submit 

exams after this date – answers to the module will be published on www.optometry.co.uk

Eyelid and Eyelid Margin disorders - Optometry Today

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