Published in Ocular Surface

The Optometrist's Guide to Blepharitis and Stress

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12 min read

Blepharitis is a chronic condition with a variety of risk factors and etiologies. For many patients, stress can be a contributing factor. Here's what to know about blepharitis and stress to help your patients move forward with their care!

The Optometrist's Guide to Blepharitis and Stress
Understand the effects of stress on blepharitis


Resurface the connection between stress and the ocular surface

It’s no doubt that during this COVID-19 era, stress is a mainstay for the entire world.
Optometrists recognize that this health crisis has propelled a societal shift to using digital devices, noting the subsequent implications of tension on the ocular system, most prominently accommodative spasms, binocular vision dysfunctions, asthenopia, and digital eye strain.
Here, we’ll uncover an ocular surface complication where stress can play a major role.
We know that blepharitis is chronic, with irritation and inflammation that leads to crusting, insipid glands, lid erythema, telangiectasia, and even blurry vision. Risk factors and etiologies of the condition vary, and interestingly, stress comes into the equation for many too! We know that stress is multifactorial--with emotional and physical effects. So, it’s no surprise that the ocular surface is another facet that stress can affect.

Stress and blepharitis

Inner workings of blepharitis

With red, burning, irritated eyes, most blepharitis patients have complaints that overlap with other ocular surface disease symptoms.
  • Anterior blepharitis includes the skin, eyelashes, and eyelash follicles.
    • Atopic dermatitis
    • Contact dermatitis
    • Staphylococcal bacterial dermatitis
    • Seborrheic dermatitis
    • Trichiasis
  • Posterior blepharitis covers the meibomian glands, tarsal plate, and blepharo-conjunctival junction.
    • Meibomian gland dysfunction (MGD)
    • Rosacea
  • Anatomical crossover of the areas occur in ulcerative dermatitis and demodex infestation.

The psychology of stress

There are three types of stress--chronic, acute, and episodic. Classification of the body’s response to stress was termed general adaptation syndrome (1). The stages of stress are:
  1. Alarm is the reaction of shock. The sympathetic system activates. The adrenal glands release cortisol, heart rate increases, and adrenaline starts coursing in the body.
  2. Resistance is the start of regulating--the parasympathetic system kicks in to achieve homeostasis. However, alertness stays transparent with symptoms of irritability and difficulty focusing.
  3. Exhaustion is inevitable as a repercussion. Typical conditions of depression, anxiety, and burnout can result (2).
Although the level of stress can deviate person to person, it’s clear that accumulation of persistent stress can cause long term consequences. Coping can be difficult, and it can be draining no matter which stage is being experienced.
Let’s dive into the compounding impact of stress on blepharitis.

Treating blepharitis when stress is a factor

Reforming the approach to blepharitis treatment during a pandemic

Prevention of blepharitis complications is key as recurrence is not uncommon. We want to create and sustain a healthy ocular environment, giving any imbalance in the normal bacterial flora a chance to stabilize. We have seen blepharitis complications lead to a chalazion or hordeolum, even formation of secondary preseptal cellulitis can be prompted.
A simple and stepwise routine for ocular hygiene is the best approach to patient education of eyelid dermatitis. Ensure 15 minutes of heat application is done and show how vertical massages mechanically clear clogged glands. Discuss your favorite gentle, antimicrobial cleansing formulations, and emphasize appropriate makeup removal methods around the eyes.

Implications of stress within the realm of blepharitis

Although the etiology of blepharitis is multitudinal, individuals who are predisposed can be triggered by certain factors such as stress. Stress behaviors are important to recognize; one may have difficulty concentrating, revert to bad habits, and fall into unhealthy eating habits.
The relevant detrimental actions that can spotlight blepharitis conditions are: trichotillomania, increase in facial self-touching, insomnia, lapses of personal care/hygiene, and eye rubbing. Pulling hair and tugging at eyelashes can be tension-caused behavior (3,4). Touching your face adds another harmful irritant, especially if eye rubbing and disruptions in routinely washing your hands and face occurs. Concomitant dry eye has also been pinpointed to poor sleep quality, displaying low TBUT and Schirmer I results (5).
All of these stress-induced actions leave room for instigating blepharitis, and even lengthening the course of the condition due to delayed wound healing.

Modes of action of stressors and triggers

Pathophysiology of stress is elaborate, starting with the brain’s HPA axis--hypothalamus, pituitary gland, and the adrenal gland (6). The adaptive effects of cortisol release impact multi-organ systems because this glucocorticoids steroid hormone has receptors spanning the CNS and PNS. Common ocular complications we see clinically include central serous retinopathy, uveitis, episcleritis, scleritis, and blepharospasm.
During the cascade of events, three major areas of regulation are the endocrine, nervous, and immune systems. Within the endocrine changes, we find connections between chronic stress and depression. Depleted serotonin and dopamine levels occur with chronically high cortisol and can cause harmful effects on cognition and behavior. Evidence shows that conditions of anxiety and depression were both higher in those diagnosed with blepharitis (7). We have to understand that our patients may be facing underlying chronic, acute, and/or episodic stress.
Cutaneous effects should be considered as well. Rosacea’s effects on the ocular system can be triggered by psychological stress, among other atopic conditions such as eczema. One molecule called neuropeptide P, affects sebaceous glands and may be of note for MGD. It alters and propagates sebaceous gland formation, disturbing the lipid synthesis process (8).
Lastly, being in a state of immune susceptibility, keep in mind that changes in normal microbial floras can take place. It’s been proven that demodex infestation can be agitated with stress, exacerbating the proliferation of the mites (9). In addition to the multiplication of ectoparasites, vulnerability also leaves room for viral infections. In fact, those reactivations of herpes infections can lead to angular blepharitis recurrences (10).

Conclusions and References

Takeaways for the blepharitis and stress relationship

Underlying complexities of both conditions provide a medium of overlap. How can we as physicians provide reassurance and plans of treatment to effectively and cohesively consider the association between stress and blepharitis?
Provide recommendations to help manage underlying systemic implications that impact blepharitis. See if your patient is up for entertaining the mind with a hobby like art or exercise. Take a more holistic approach and share how meditation and yoga encourage mindfulness. Engaging the parasympathetic system with deep breathing or techniques like the "butterfly hug" can help for anxiety relief. And educate about the benefits of good sleeping patterns! Discuss the option of blue light blocking glasses and night mode to avoid circadian rhythm disruptions when advisable.

How to address stress in blepharitis patients

As a recent graduate, I have faced the tension of starting my career in a pandemic. But I quickly learned that as doctors, we are in a unique position to notice that every person carries different stories and struggles. Due to the COVID-19 outbreak financial trouble, grieving loss of loved ones, social isolation, and psychological stress are evident, among many challenges.
67% of Americans state they had higher amounts of stress in 2020 due to coronavirus, according to a report by American Psychological Association. It is imperative that a psychiatrist or therapist referral be considered for patient-centered care when appropriate. The simple conversation can cause patients to be more inclined to pursue help. During a pandemic, ODs must take care of our own stress—but we can use those tips to help our patients, too.
In clinical practice, we can easily bridge the awkward but necessary conversation of addressing lid hygiene, with something every single person can relate to (especially during a pandemic). Ask if the patient has been stressed! Say you notice blepharitis and it can be linked to underlying stress. Convince them by taking an anterior segment photo or googling a photo!
Let us take the risk of addressing blepharis by asking about stress. The bottom line is that the chronic nature of stress and blepharitis both require maintenance therapy for management. Ultimately as eye care physicians, we need to ensure patients commit to the cleanliness of their eyes, and we need to provide a safe space to discuss how associated underlying stress can manifest as a risk factor.


  1. Waude A. How Your Body Copes With And Adapts To Stress With General Adaptation Syndrome. Psychologist World. Published March 5, 2016. Accessed March 10, 2021.
  2. SELYE H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-1392. doi:10.1136/bmj.1.4667.1383
  3. Mueller SM, Martin S, Grunwald M. Self-touch: Contact durations and point of touch of spontaneous facial self-touches differ depending on cognitive and emotional load. PLOS ONE. 2019;14(3). doi:10.1371/journal.pone.0213677
  4. Katie Hurley. What is Trichotillomania? A Closer Look at Hair-Pulling Disorder. - Mental Health Treatment Resource Since 1996. Published November 24, 2020. Accessed March 12, 2021.
  5. Wu M, Liu X, Han J, Shao T, Wang Y. Association Between Sleep Quality, Mood Status, and Ocular Surface Characteristics in Patients With Dry Eye Disease. Cornea. 2018;38(3):311-317. doi:10.1097/ico.0000000000001854
  6. Smith SM, Vale WW. The role of the hypothalamic-pituitary-adrenal axis in neuroendocrine responses to stress. Dialogues Clin Neurosci. 2006;8(4):383-395. doi:10.31887/DCNS.2006.8.4/ssmith
  7. Chiang C-C, Lin C-L, Tsai Y-Y, Peng C-L, Liao Y-T, Sung F-C. Patients with Blepharitis Are at Elevated Risk of Anxiety and Depression. PLoS ONE. 2013;8(12). doi:10.1371/journal.pone.0083335
  8. Torjesen I. Psychological stress as acne cause. Dermatology Times. Published September 13, 2018. Accessed March 10, 2021.
  9. Liu J, Sheha H, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510. doi:10.1097/ACI.0b013e32833df9f4
  10. Jakobiec FA, Dobli Srinivasan B, Gamboa ET. Recurrent Herpetic Angular Blepharitis in an Adult. American Journal of Ophthalmology. 1979;88(4):744-747. doi:10.1016/0002-9394(79)90676-7
Sasha Patel, OD
About Sasha Patel, OD

Dr. Sasha Patel is an optometrist who was raised in Macon, “the heart of Georgia.” This is where she hustled as a competitive gymnast for 10 years. Her goal of achieving a perfect 10 soon became one of providing patients with perfect 20/20! Dr. Patel completed her undergraduate studies at Georgia Institute of Technology and earned her doctorate of optometry from Nova Southeastern University.

Her passion resides in primary eye care and ocular disease, with emphasis on dry eye and nutritional eye care. Currently, she offers optometric care in Fairfield County in the state of Connecticut.

In her free time, she enjoys a cup of morning chai, making jewelry, and acrylic painting.

Sasha Patel, OD
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