Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Blepharitis: remains a diagnostic enigma. A role for tea tree oil shampoo?

Blepharitis is an inflammatory condition of the eyelid margins and likely to be the most under-diagnosed, undertreated, and underappreciated eye disease worldwide.1 Traditionally, clinicians classify it into anterior or posterior blepharitis, with the latter associated with meibomian gland dysfunction and the former with local microbial colonisation or seborrhoea.

In the past, the terminology of blepharitis has been vague but over the past few years, the International Workshop on Meibomian Gland Dysfunction have produced a series of publications aimed to clarify the classification and summarise the literature on aetiology, pathophysiology, and treatment.1, 2, 3 However, blepharitis remains a diagnostic enigma, with a variety of treatments with variable levels of efficacy, reflecting the poor understanding of aetiology.

In this issue, Dadaci et al4 investigated the microbial flora of the eyelid margin and show excessive microbial colonisation of the lids in patients with blepharitis. The authors found that fungal elements were detected with periodic acid-Schiff staining in approximately four out of five patients with chronic anterior blepharitis.4 Fungi, specifically Pityrosporum yeasts, have been implicated in blepharitis as early as in 1990; in a placebo-controlled clinical trial, published in Eye, treatment with ketoconazole 2% cream on the lid margins markedly improved the clinical severity of blepharitis.5 Coagulase-negative Staphylococcus, Staphylococcus aureus, and Propionibacterium acnes are common commensal microbes that may contribute to the pathophysiology of blepharitis.6

Dadaci et al,4 also found that there were high levels of Demodex infestation. Other investigations of Demodex show that infestation of lash follicles is associated with the occurrence of anterior blepharitis.7 In a large study involving 335 patients, the number of Demodex mites correlated significantly with the severity of ocular surface discomfort; treatment with tea tree oil reduced the Demodex counts and improved subjective ocular symptoms.8 The variety of pathogens implicated in blepharitis may also explain the beneficial effect of broad-spectrum treatments, such as lid scrubs with tea tree oil and shampoo. Tea tree oil exerts not only anti-Demodex properties, but also broader antibacterial, antifungal, and anti-inflammatory actions that may enhance its therapeutic potential.1, 9

However, the presence of microbes on the lid margin of patients with blepharitis does not imply causality. Excessive colonisation may be an epiphenomenon, indicating the possibility that microbes find the altered eyelid environment in blepharitis more hospitable than that of the normal eyelid. Keratinisation of the lid margin epithelium, keratinised cell debris, and the abnormal lipids in blepharitis all provide a rich substrate for microbial pathogens.1 Patients with chronic blepharitis are often treated with antibiotics and steroid drops, a treatment that may also alter the resident commensal flora and favour excessive colonisation with selective bacterial or fungal microbes.

It must be emphasised though that this alteration of conjunctival microbial flora does not represent an infection. In addition, the matter is made more complex in the presence of posterior blepharitis where the primary aetiology is the occurrence of meibomian gland dysfunction.

Irrespective of whether fungi, bacteria or other pathogens are the primary cause of blepharitis, there is strong suspicion that excessive microbial colonisation contributes to the pathophysiology of the condition. Bacterial lipases and toxins could alter the lipid composition and destabilise the tear film, with the production of toxic-free fatty acids, causing evaporative dry eye.10 The secondary production of pro-inflammatory cytokines, neutrophil chemotaxis, and reactive oxygen species production are all pathogenic to the ocular surface.1 The detrimental role that microbes may have in blepharitis is also supported by the beneficial effect antibiotics have in patients with this condition.

Progress in elucidating the aetiology of this poorly understood condition, as demonstrated by the work of Dadaci et al4 and others is being made. With greater research in this area and greater acceptance of the diagnostic criteria set up by international workshops, more target specific and long-term treatments for patients with blepharitis will no doubt emerge. In the meantime, clinicians are left with making pragmatic options to reduce microbial flora based on their own experience. Anyone for a drop of tea tree oil shampoo?

References

  1. Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O'Brien T et al. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2011; 52: 2050–2064.

    Article  Google Scholar 

  2. Nichols KK . The international workshop on meibomian gland dysfunction: introduction. Invest Ophthalmol Vis Sci 2011; 52: 1917–1921.

    Article  Google Scholar 

  3. Knop E, Knop N, Millar T, Obata H, Sullivan DA . The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci 2011; 52: 1938–1978.

    Article  Google Scholar 

  4. Dadaci Z, Kılınç F, Ozer TT, Sahin GO, Acir NO, Borazan M . Periodic acid–Schiff staining demonstrates fungi in chronic anterior blepharitis. Eye (Lond) 2015; 29: 1522–1527.

    CAS  Article  Google Scholar 

  5. Nelson ME, Midgley G, Blatchford NR . Ketoconazole in the treatment of blepharitis. Eye 1990; 4 (Pt 1): 151–159.

    Article  Google Scholar 

  6. Dougherty JM, McCulley JP . Comparative bacteriology of chronic blepharitis. Br J Ophthalmol 1984; 68: 524–528.

    CAS  Article  Google Scholar 

  7. Kheirkhah A, Casas V, Li W, Raju VK, Tseng SC . Corneal manifestations of ocular Demodex infestation. Am J Ophthalmol 2007; 143: 743–749.71.

    Article  Google Scholar 

  8. Koo H, Kim TH, Kim KW, Wee SW, Chun YS, Kim JC . Ocular surface discomfort and Demodex: effect of tea tree oil eyelid scrub in Demodex blepharitis. J Korean Med Sci 2012; 27: 1574–1579.

    Article  Google Scholar 

  9. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC . Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007; 26: 136–143.

    Article  Google Scholar 

  10. Dougherty JM, McCulley JP . Bacterial lipases and chronic blepharitis. Invest Ophthalmol Vis Sci 1986; 27: 486–491.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to P Hossain.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hossain, P., Konstantopoulos, A. Blepharitis: remains a diagnostic enigma. A role for tea tree oil shampoo?. Eye 29, 1520–1521 (2015). https://doi.org/10.1038/eye.2015.139

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/eye.2015.139

Further reading

Search

Quick links