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!
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.
With red, burning, irritated eyes, most blepharitis patients have complaints that overlap with other ocular surface disease symptoms.
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:
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.
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.
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.
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).
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.
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.
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