A painful Inflammation of the Eyelids

from Dr. William Harris (a mere Ph.D.)

It is a snowing December morning in Vermont and I am reminded of the time a few years back when I began to find the brightness of winter light annoying, and started hanging curtains over the large windows in my study. I had a successful cataract operation on both eyes a few years before and thought that the much improved vision was responsible for this new sensitivity to light. But when my eyelids became red, I went to my ophthalmologist, and he said it was Blepharitis, explaining in detail the causes of this common condition and prescribing a suitable medication.

But curing the inflammation was not that simple, and it took some time to get the condition under control. So I am going to write a short chronicle of my dealing with Blepharitis in hope that this may be useful to others who suffer from this minor but most agonizing condition. About eighty five percent of our incoming information arrives through the eyes, and anything which interferes with the easy and automatic function of our visual apparatus is at the front line of our attention all the time. Blepharitis interferes with not only the use of our eyes, it becomes an additional annoyance in the often difficult business of getting on with our lives.

First, we should have a clear understanding of the eyelids or "blephara" , what they are and how they work. Let me first of all give an clear anatomical description of the lids and their operation from the classically clear writing of Marshall-Lazier 4 ed. back in l955:

"The eyelids contain a central core of connective tissue and muscle, and a covering of skin and membrane. The connective tissue is largely condensed into the tarsial plates which give body to the lids. The eyelids are closed by the 'orbicularis oculi muscle'. A slip of superior rectus muscle. The 'levator palpebrae [lid]' inserts on the upper lid and opens the eye, assisted by some smooth muscle fibers in each lid. When the eye is open, the levator palpebrae works with the muscles of the eye to keep the edge of the upper lid halfway between the upper edge of the pupil and the upper edge of the iris in all positions of the eyeball."

"The skin covers the superficial surfaces of the lids; the 'conjunctiva', a white glistening membrane lines their deep surfaces and is reflected from them on to the anterior aspect of the eyeball. On the free margins of the lids the eyelashes and the openings of a number of glands may be found. The stratified epithelium on the outer surface of the cornea is continuous with that of the conjunctiva, and the latter is continuous with the epidermis."

From this we can see that there are several interconnected aspects of the eyelid.

First, the lid involves a complex association of the tissue which give it its body, along with an internal lining of white glistening conjunctiva, which is continuously connected both with the cornea at the front of the visual part of the eyeball, and also with the epidermis or skin which covers the outside of the eyelid. This continuously folding membrane acts like a lining and protective sheet which seals in the eyeball and its musculature, while reaching out to the skin at the outer lip of the eyelid to seal out foreign material. It is as if an organic SaranWrap were vacuum sucked into the front of the eye socket to seal the moving eyeball to the moving eyelid, thus providing a dustproof protection for the front of the eyeball, which can still move easily in the liquid provided by the lachrymal tear-glands along with the lid's oil producing glands. This is a remarkably constructed little dirt and waterproof pocket, which may not have been needed for our remote lidless fish ancestors, but is absolutely required for living in an airborne atmosphere.

Second, there is a set of muscles which operate the lids, of which the most important is the 'orbicularis oculi muscle', a ring or sphincter muscle like that of the mouth or anus, which can close the eye in sleep. But this muscle is in continuous use throughout the day, it spreads the tear gland liquid and the lid eye gland oil over the cornea and inner folds of the lid to ensure easy motion of the eyeball in all positions. The normal eye blinks almost continuously whenever we change the eye's direction or refocus it for distance, and this keeps the muscles in an actively relaxed state. Staring without blinking while reading or watching TV produces tension around the eye and often results in eye related distress and headache. Moving the eye muscles by swinging the head, along with blinking every few seconds, is the classic eye-relaxation technique, and important for establishing a natural regimen for best vision.

The eyelid is not simply a device to close the eye for sleep and swish out foreign matter during the day. It is connected to the whole ocular system by a remarkable set of links, which permit the brain as operating control, when receiving danger signal of an intruding object (an insect or a baseball in size) from the retinal imager, to activate the 'orbicularis' to close the eye protectively, in the matter of a few milliseconds. It is this close coupling of the lid with the optic eyeball feeding directly back into the sensory part of the brain, which makes the eyelid such a sensitive and at times pain-susceptible device. All places where the internal surfaces of mucous membranes verge into the epidermis or skin are very sensitive, specifically these are the lips, the anal ring and the vaginal lips; but none of these is as closely triggered for action as the eyelid. The process by which one can 'propriocept' a speaker's sounds from a visual image of his lips with you own slight mimetic responses, might be the closest analog to the circle of sight-action response with the eyelid. I mention this to stress the point that the eyelid is no insignificant part of the human anatomy. It is on the other hand a remarkable evolutionary development as life proceeded from a sea setting to land and air.

Third, and most important for anyone suffering from blepharitic pain or inflammation, is the leading edge of the eyelid itself. This is where blepharitic inflammation first appears with its characteristic redness and itching. The immediate source of trouble comes from the oil produced for eyeball lubrication by the set of glands which open right inside the eyelashes. It is especially in winter when house atmosphere becomes dry with hot air or wood fire heating systems, that Blepharitis is most likely to occur. Washing one's face the morning normally removes excess oil, but when the oil builds up it will house bacterial activity, which quickly inflames the edge of the eyelid surface. This is the start of a classic Blepharitis condition, and the first step is quite naturally to clean the eyelid edge regularly and thoroughly each day.

The simplest cleansing process, which is also recommended before any sign of inflammation occurs, is to wash around the eyes with warm water, then rub the fingers lightly and laterally across the closed eyelids. This should remove any accumulated oil on the lid edge, and if practiced regularly blepharitis may never occur. I have found the two inch cotton discs used for makeup very good for washing the lid edges, they are soft and absorbent and inexpensive enough to use new each day. The technique of winking while washing is important to master: You do not want to touch the cornea at front of the eyeball, since it is very sensitive and can cause pain if abraded. On the other hand it repairs itself automatically if lightly contacted, so this is not something to worry about. The lower lid is easy to wipe clean since the levator muscle will pull the upper lid up out of the way for a clean wipe. But the upper lid is a little harder to access. I have found the best way for me is to press the warm and wet cotton disc against the closed eyelids, the raise the upper one by its own muscle very slightly so when it is lowered again, it self-wipes itself on the cotton pad. This is done slowly and gently without touching the eyeball, cautiously at first, but when once mastered it is as easy to do as the lower lid. Both are of course equally important since the oil glands are built into both eyelids.

If cleansing the lids for a few weeks does not clear up the inflammation, you will want to go to your doctor for a prescription. I was already working with a surgical ophthalmologist and went back to him, but any licensed optometrist can deal with this condition, and I have known general practice M.D.'s and dermatologists who have worked with blepharitis regularly. My first prescription was for ointment Maxitrol, a complex antibiotic medication with several active components and a preservative, but I found this caused skin redness around the eye, and later changed to Blephamide which has similar preservative but seemed better. My ophthalmologist regretted the disappearance from the current pharmacy of a single component ophthalmic antibiotic , but felt that a few drops of Prednisone Forte on the closed lids twice a day for one week might be effective as non-continuous use, since Pred used regularly on the eyeball will raise intra-ocular pressure. There are other antibiotics which may be available to bring the lid under control, and for maintenance Acular drops as an ophthalmic NSAIA may be considered by your doctor.

If you look up information on Blepharitis, you will find it described as a seborrheic condition, which means that it is initially caused by body oil accumulating on the lids. But since seborrhea is a general body condition which can cause skin eruptions at any place in the skin, this may seem to confuse the present situation. In fact, we are dealing with three sources of oil which can cause the inflammation and bacterial activity at the eyelid edge, which are:

First, there is oil from the lash-line glands, which we have been speaking of above.

Second, there is oil from the skin of the lids and the immediate facial area, which can spread onto the sensitive lid-lash area during the day as you rub your eyes or unconsciously pass a hand over your face. An oily gland right behind the earlobe is the old-fashioned machinist's source of a touch of delicate oil for his micrometer faces, and a natural place to pick up oily material for those of us who put our glasses on and off.

Third, there as oil from your hair, a rich supply which we will invariably pick up from combing or rustling our hair, especially during the long period of sleep. Waking in the morning many of us rub our eyes as an automatic gesture, adding hair oil to eyelid oil to reinforce the eyelid gland oil ----- and we have perfect conditions for a good case of Blepharitis.

The answers are simple: Clean eyes each morning, thinking of the critical oil glands at the lash-line first, and then of the skin on the lid around the eye opening. A non-soap skin cleanser may be required, in any case keep anti-perspirant and scented soap away from your morning eye cleaning. Washing your hair in the shower is a normal part of many Americans' ablutions, a good idea for the blepharitic eye, but again keep that powerful and oil-rich shampoo out of the eye area.

So there is relief from Blepharitis, which can start from humidification of the living space, proceeding to a regimen of daily cleansing of the lids and eye areas, with attention to whole body oiliness on skin and hair. Initially an antibiotic may be required if the lids are inflamed, but after your doctor does his work the rest will be up to you for a program of maintenance, always on rising at morning and if possible again before going to bed. Overdoing cleanliness should not be seen as a waste of effort but a matter of continued security from trouble, since blepharitis has a tendency to become chronic if not watched carefully.

Blepharitis and the Lid Muscles

When you experience a blepharitic condition, your body will react by tightening up the facial and eyelid muscles which control eyelid motion. It may be that the resulting tension around the eye becomes habitual, even after medication and washing relieves the immediate oleaginous problem with the eyelids. So it is well worth investigating some techniques which can help to put the eye-surround musculature back into the normally relaxed state. A long bout with blepharitis may make this more difficult, since tensions tend to become matters of habit, so there are further things to consider after getting the eyelid edge back to normal.

For many years since early the work of William Horatio Bates (1860-1931) with his book "Perfect Sight Without Glasses", there was a worldwide interest in improving sight, evidence of which can be found in a current google search on this subject, returning some 759 returns to date. As a glasses laden boy I was seen by a doctor in this tradition, one Harold Peppard, and remember his exercise of swinging the body while look at a point, and blinking regularly especially when changing direction of vision of shift of focus. These and such exercises seem to have made a mild effect on the ability of the internal eye muscles to move the lens into a better focus, and although this could help minor vision deficiencies, it was of little use in mid-age presbyopia as the eyeball became rigid against focus. In modern times with laser surgery to correct vision, we might look back on Bates' work with a smile of amusement, but there are things about eye relaxation to be learned from that period.

When you say your eyes are tired, you are not talking about the internal ocular organ, which transmits light signal neurally and does not experience fatigue from use. Attention may lag but the eye works on without losing data, while it will be the network of activating muscles working the eyeball and eyelids which become stiff and cramped. After my experience with blepharitis was cured, I still felt muscular tension in the ocular area, and by pure chance remembered the exercise part of Peppard's much touted l940 book "Sight Without Glasses".

TV or work with the computer are great situations for freezing the eye muscles. Several hours of staring at the screen with small lateral eye shift and little reason to blink with refocus, can leave us with a frozen facial musculature. I have found that moving my head in each of the four directions while watching the screen causes a wide range of opposing (antagonistic) muscles to go through their full cycles of pulling and relaxing, and eye stress is greatly relieved. Note that this applies to the rotating muscles which work the eyeball, so another set of exercises for re-instituting the normal blink on a few second interval will do the same thing for the surrounding muscles. It is especially after becoming sensitive to a blepharitic condition, that we forget these normal uses of our optic equipment. If you have any question, try this the next time you feel tired working before a monitor and see if it does for you what I find it does for me.

The snow is still coming down, looking out from my studio window into the falling flakes which are starting to mask out the pine trees over against the old stone fence, I let my eyes rest while I pivot gently right and left from my chair at the computer desk, blinking my eyes as if in an effort to catch the descent of snowflakes before they fall into the white blanket which covers the lawn. I have been typing all morning on this paper, and can now breath easier knowing that an hour more with the spelling and a few tweakings of sentences, and it will be ready to be sent to the internet. But I thought this would be a good time to test my advice, and see if I can let me eyes get back to rest.

My eyes are now relaxed as I watch the interminable fall of the snowflakes, each a complete individual falling all day and into the dark of night without pause. The brightness of the winterscape no longer glares my eyes, and I think I have the situation under control. This is, after all, the reason for putting these thoughts down on my computer hard drive, perhaps for others' use sometime, somewhere on our world of expanding global experience.

My medical advisors Dr. I. C. Clearly and Dr. Iris Seymour have withheld their review of the paper on the grounds that it does not include a control and placebo procedure, hence cannot be taken seriously. They feel that any opinion offered might compromise their impartiality. Sic transit gloria mundi......

(Dr.) William Harris
Prof. Em. Middlebury College