Eyelid cleaning: Methods, tools, and clinical applications

Abstract

Nowadays, people give more importance and pay closer attention to the condition of their eyelids and lid margins. This increased recognition of eyelid hygiene is due to the growing awareness that improper eyelid cleaning might lead to various ocular surface diseases such as blepharitis and meibomian gland dysfunction. These ocular surface diseases can greatly affect people's quality of life. This article reviews the latest procedures for proper eyelid cleaning, including indications, methods, tools, detergents, and clinical applications, to maintain a healthy ocular surface and assist in the treatment of dry eye and blepharitis.

The hygiene condition of eyelids and lid margin is critical for maintaining ocular surface health.[1] Poor lid hygiene condition is related to dry eye, meibomian gland dysfunction (MGD), and blepharitis. The lid margin is often not cleansed effectively due to the skin folds covering the margin when the eye is closed. The lid margin has two important structures: (1) lash roots with hair follicles, and (2) meibomian gland orifices, which excrete the oil layer of the tear film across the surface ocular.[2] When lash roots are unclean, they cause the flourishing of Demodex, a common human ectoparasite related to blepharitis, and a dirty lid margin causes the blocking of the meibomian orifice, which is related to MGD and dry eye.[3,4]

With further research and understanding of the microorganisms and the microbiome on the ocular surface,[5] people's awareness of the importance of proper eyelid and lid margin cleaning has been increased.[1] Inflammation occurs in response to a weakened immune system and invasion of microorganisms.[6,7] Effective eyelid hygiene is important to reduce bacterial overgrowth and maintain ocular surface health. This article summarizes eyelid cleaning and related content in recent years [Fig. 1].

Figure 1.

In-office cleaning and at-home cleaning. (a) Demodex (arrows) and squamous debris (arrowhead) on the eyelash and eyelid margin was obviously hyperemic before treatment. In in-office lid margin cleaning, participants should be instructed to lie comfortably on a therapeutic bed. Cleaning tools include cleaning devices, cotton balls, and swabs. Cleaners contain iodophor, povidone–iodine, medicinal alcohol, hydrogen peroxide, and high-concentration tea tree oil. (b) At-home lid margin cleaning is suitable for a small amount of debris on eyelashes and mild hyperemia of the lid margin. It needs to be done after washing hands and face. Cleaning tools include cotton swabs, lid brushes, sponge pads, and wipes. Cleaners contain baby shampoo, soap, facial cleanser, low-concentration tea tree oil, low-concentration T4O, low-concentration hypochlorous acid, low-concentration okra oil, 3% boric acid solution, and specially formulated cleaning solution

Search methods

A literature search was conducted on PubMed on March 28, 2023 by using the following search term: “(eyelid hygiene OR lid margin hygiene OR lid cleaning OR) AND (dry eye OR DED).” Two researchers (LZ and JW) independently reviewed the article, and where they encountered disagreements, they discussed until a consensus was reached. The inclusion criteria were original, peer-reviewed articles assessing tools, methods, and clinical applications related to lid hygiene. Articles without available letters to the editor and case reports were excluded.

At-home eyelid cleaning

At-home eyelid cleaning refers to the cleansing of the eyelids that people routinely do domestically by both healthy individuals and patients affected by lid margin hygiene-related diseases. Daily eyelid cleaning products are commercially available, which people can use as advised by their doctors or by following the cleaning instructions.

Common cleaning solutions and main ingredients

Baby shampoo, soap, facial cleanser, and other daily cleaning supplies

The earliest detergent used for eyelid cleansing can be traced back to the 1950s when selenium sulfide-based shampoos were first used to treat seborrheic blepharitis.[8] For a long time, it was considered the common product of eyelid cleansing and assisted in the treatment of various eyelid hygiene disorders. Over time, baby shampoo gradually became the primarily used eyelid cleanser owing to its mildness, low irritation, and its ability to effectively cleanse the eyelids.[9] Studies have found that using baby shampoo to cleanse the eyelids can remove lid margin secretions and scales, help control inflammation, and greatly improve symptoms of blepharitis.[10,11,12] Soaps, cleansers, and other detergents are also commonly used in healthy populations to maintain lid margin cleanliness. These cleansers need to be diluted for usage, and the concentration differs individually. However, these cleansers do not contain therapeutic ingredients, such as antibiotics, and are thus not effective in removing Demodex infection from the roots of the eyelashes.

Clinical trials testing baby shampoos as an eyelid cleaner at a 1:10 dilution solution have found that the expression of mucin secretion MUC5AC is decreased dramatically. The considerable decrease in MUC5AC secretion suggests that diluted baby shampoo can cause damage to conjunctival goblet cells, causing dry eye in the patient or exacerbating the patient's existing dry eye condition. The effect of baby shampoos on the patient's natural ocular surface environment demonstrates the need for patients to carefully select appropriate detergents for daily eyelid cleaning.[13]

Low-concentration tea tree oil

Tea tree oil (TTO) is an oil extracted from the leaf of Melaleuca alternifolia. TTO has antiparasitic, antibacterial, antifungal, and anti-inflammatory properties, making it a practical detergent for proper lid hygiene. Gao first reported that TTO diluted to the correct concentration can be used to effectively treat a Demodex infection.[14,15] Gao also reported good clinical results with the use of 5% TTO for the treatment of patients with Demodex blepharitis.[16,17,18] Many reports suggest that improvement in symptoms, disappearance of eyelash scales, and reduction of Demodex have been observed after cleansing the lid margin by using TTO products.[19,20,21] Studies have also shown that it can be useful in the treatment of MGD.[22,23]

Currently, 5% TTO lid scrub pads have become commercially available and are used worldwide. Although TTO is thought to be a well-rounded eyelid detergent, including its therapeutic use in Demodex ectoparasite infection, the potent odor of TTO may cause irritation and discomfort at high concentrations or over a long period of exposure. Many patients complained of mild to moderate discomfort during the use of TTO products, especially the elderly and children as they tend to have more sensitive skin.[24,25,26]

TTO with a concentration of 0.02% cleaning foam is a relatively mild product and is thus less likely to cause skin irritations on the skin. Research shows that it is more popular among patients; however, its Demodex removal effect is not as good as other high-concentration TTO products.[17]

Low concentration of Terpine-4-ol

Terpine-4-ol (T4O) is the most abundant and effective component of TTO and is highly irritating yet more effective in Demodex removal and has a remarkable Demodex-killing effect.[27,28] Commercialized T4O eyelid cleaning wipes are available, and its mite-killing action works by inhibiting superoxide production and enhancing the natural immune response.[29,30] It can produce more pro-inflammatory mediators such as IL-8 and IL-12p70. These mediums can kill Demodex by competitively blocking acetylcholinesterase (AChE), a neurotransmitter terminator enzyme in parasites. In addition, T4O has antifungal, antibacterial, and anti-inflammatory characteristics. Several studies have shown that T4O products have good acaricidal effects even at concentrations as low as 0.5%.[31,32,33]

Low-concentration hypochlorous acid

Low-concentration hypochlorous acid is considered a safe and effective disinfectant with a common concentration of 0.7%–0.9%.[34] Studies have proved that it has good antibacterial and antiviral properties and can effectively remove biofilm.[35] Staphylococcus aureus is particularly sensitive to it. It can also reduce the expression of inflammatory factors such as histamine, matrix metalloproteinase-9, and interleukins-1 (IL-1) and IL-6 in damaged skin; however, it does not have the effect of killing Demodex.[36] Hypochlorous acid solution can reduce bacterial accumulation in the ocular skin. Several studies have demonstrated the efficacy of hypochlorite eyelid cleansing in different types of blepharitis in improving ocular symptoms, reducing the degree of conjunctival and lid margin congestion, and increasing tear film stability.[37,38]

Boric acid solution with a concentration of 3%

Boric acid solution is a colorless and clear disinfectant, with a slightly weak antibacterial effect and little irritation. Although it cannot easily penetrate the complete skin layer, it can penetrate the damaged skin mucosa. It is commonly used for disinfection of skin, mucosa, and wounds, especially for vesicular exudative skin diseases. Boric acid solution with a concentration of 3% is widely used in dermatology for its anti-swelling, anti-inflammatory, astringent, and anti-itching effects, and can be rinsed or applied wet.[39] In ophthalmology, boric acid solutions are used for eye irrigation in eyelid wounds and acute chemical injuries.[40]

Low-concentration okra oil

Okra inhibits the Akt-mediated NF-κB pathway in mouse BV2 microglia cells, which has been demonstrated to play a role in anti-inflammatory actions.[41] A study conducted on eyelid wipes containing okra confirmed that it is effective in cleansing lid margin scales and peristomal mites, improving symptoms of blepharitis.[42] Compared with TTO, it has less irritation and good patient compliance. However, its in-vivo acaricidal effect was not as good as that of TTO, and in-vitro acaricidal tests have not yet been reported.

Specially formulated cleaning solution

Studies have shown that some compound eyelid cleansers have milder ingredients and are less irritable among those who need eyelid cleansing. They can greatly reduce lid margin congestion while being slightly less effective at removing Demodex.[43] Some detergents can improve symptoms while promoting eyelash growth, making them more popular among women.[44] Part of eyelid cleansing gel can not only clean eyelids but also provide refreshment and temporarily relieve eyelid discomfort.[45]

Common domestic cleaning methods

Finger massage cleaning

In most studies, the researchers instructed the subjects to clean by finger massage, which is sensitive to skin pressure and can be adjusted to keep the eyelids in a comfortable state [Fig. 2]. Because no pad or towel is used, the friction on sensitive eyelid skin is reduced. However, there may be some shortcomings, such as inability to clean deeper parts of the eyelids and insufficient cleaning strength to remove biofilm and any parasites that may be present.

Figure 2.

To perform the cleaning, the fingertip was utilized to softly massage the upper and lower lid margins, meibomian orifices, and the base of the eyelashes. Participants were instructed to gaze downward while cleaning the upper lid margin and upward while cleaning the lower lid margin to prevent any touching the cornea

Cotton swabs, lid brushes, and sponge pads

The swab and the eyelid brush are disposable items with large ends and are thus clean, sanitary, sterile, nontoxic, and less irritating. Instead of finger contact, they can take more detailed care of each part of the eyelid. Tanabe et al.[46] designed the eyelid brush to effectively clean the surface of the eyelid margin without touching the cornea; the tool includes a wiping material, a support with the wiping material attached, and a gripper attached to the support. Sponge pads are soft cleaning tools that provide a comfortable cleaning experience while potentially lacking in adequate cleaning ability because of being too soft.[47]

Cleaning wipes

Cleaning wipes are pre-soaked with detergents and are recommended for eyelid cleaning for outdoor travel and at home. They are the most popularly used eyelid cleaning method with the characteristics of being portable, sterile, and disposable.[48] Current commercial wipes include TTO wipes, T4O wipes, okra oil, and hypochlorite wipes. These wipes greatly reduce the microbiota on the eyelids are more comfortable and can be easily used by patients.[49,50]

Hospital eyelid cleaning

Hospital eyelid cleansing is performed by eyecare professionals in-office for different types of blepharitis, such as Demodex blepharitis, squamous blepharitis, blepharokeratoconjunctivitis (BKC), MGD, dry eyes, ocular trauma, and routine procedure prior to selective ophthalmic surgery. It can be used alone or in conjunction with home cleansing.

Common cleaning solutions and main ingredients

Iodophor, povidone–iodine, and medicinal alcohol

When disinfecting areas of eyelid trauma or for eye surgery, disinfectant products are often used to clean the eyelid to prevent microorganisms from entering through the break and causing an inflammatory reaction. Iodophor and medicinal alcohol are highly irritating to the eye and need to be used with caution to prevent entry into the eye.[51] Therefore, iodophor has been less commonly used for disinfection and cleaning of the ocular surface. Povidone–iodine solution at 0.5%–1% concentration has become a routine disinfectant cleaner because it causes less irritation. At this concentration, most bacteria can be killed without considerable irritation to the skin.[52,53]

Hydrogen peroxide

Hydrogen peroxide is commonly used for eyelid trauma debridement and can effectively inhibit bacteria, especially anaerobic bacteria.[54] Contaminated and infected wounds should be flushed using 3% hydrogen peroxide solution before eluting with saline to thoroughly remove dirt and foreign bodies from the wound.[55] Hydrogen peroxide can cause keratoconjunctival injury; thus, it should be avoided on entering the ocular surface during use.

Highly concentrated tea tree oil

The use of 50% TTO for lid margin cleaning in hospitals has been reported to be effective in killing Demodex and relieving ocular symptoms.[15,24] There have been many reports suggesting that 50% TTO has a satisfying Demodex removal effect. The high concentration of TTO irritates the ocular surface, and improper use can lead to damage to the cornea and conjunctiva epithelium, thus requiring to be done by professional medical workers.[56]

Common hospital eyelid cleaning methods

Eyelid cleaning assisted by high-speed rotary electric cleanser

The high-speed rotating electric cleanser is a device used for adjuvant treatment of blepharitis, MGD, and other ocular disease.[57] It comprises an electric handle and a disposable cleaning brush head. Through repeated friction between the electric brush head and eyelid margin, it can safely and effectively remove scales, keratinized epithelial tissue, and biofilm. Murphy et al.[58] used an electric cleanser as an adjunct to treatment. The subjects used a cleaner for scrubbing every night, followed by a hydropathic compress with a wipe containing TTO. The results showed that the number of Demodex decreased, and the symptoms improved significantly in the population using the cleaner. Xie et al.[59] obtained good results with a deep cleaning device for MGD, which was considered to be an effective and convenient cleansing modality, with only some patients experiencing itching sensation during use. Wang et al.[60] concluded that deep eyelid margin cleansing can further enhance the effectiveness of TTO eye patches in removing Demodex more thoroughly, improving the abnormal lid margin performance, and maintaining a clean state.

Cotton balls, cotton swabs, wet wipes, and lid brushes

Cotton balls and cotton swabs, as the most common disinfection and cleaning tools, are often used to touch the appropriate amount of detergent, rub the base of eyelashes, and remove oily secretions and scales.[61] Ngo et al.[25] designed a combination of a cotton stick and a disposable plastic tubing, which contained 50% TTO, and the sponge tip of the cotton stick was moistened by applying pressure to the breakthrough of the plastic tubing; however, it is irritating and can cause to keratoconjunctival epithelial injury, thus limiting its promotion application.

Clinical Application of Eyelid Cleansing

In clinical practice, eyelid cleaning is often used. This review summarizes some common situations that require eyelid cleaning [Fig. 3] and part of studies on eyelid cleansing [Table 1].

Figure 3.

Conditions that necessitate eyelid cleaning. (a) Blepharitis, a large number of squamous debris on the eyelid margin. (b) Eyelid redness and swelling. (c) Meibomian gland dysfunction, meibomian margin vesicle, and meibomian gland opening obstruction. (d) Steven–Johnson syndrome, eyelid skin ulcer, and erosion

Table 1.

This table compiles the literature on eyelid hygiene in recent years, including sample size, cleansers used, and cleaning tools, and provides a summary of the research findings from these studies

Study	Sample Size	Cleanser		Tools		Results
		Intervention	Comparison	Intervention	Comparison
Tanabe et al. (2019)[46]	6 subjects (6 M)	Eye shampoo (MediProduct Co., Ltd., Tokyo, Japan)	Tap water	Eye brush	Finger	Using a new type of eye brush with lid hygiene shampoo can safely and effectively clean the lid margins of healthy individuals.
Aryasit et al. (2020)[11]	60 patients with grade-2 MGD (15 M, 45 F)	OCuSOFT Lid Scrub Original Foaming Eyelid Cleanser (OSO)	Baby shampoo (BS) (Johnson's® No More Tears®)	Finger	Finger	Both BS and commercial eyelid cleansers were effective in improving the symptoms and signs of MGD.
Mergen et al. (2021)[73]	52 patients with seborrheic blepharitis	Swabs containing tea tree oil and chamomile oil	BS (Johnson's® No More Tears®)	Cotton swabs	Fingers	Swabs containing TTO and chamomile oil were as effective as BS in reducing the severity of seborrheic blepharitis symptoms and improving MGD.
Sung et al. (2018)[13]	43 patients with blepharitis (16 M, 27 F)	Dedicated eyelid cleanser (TheraTears® SteriLid®)	Dedicated BS (Johnson's® No More Tears®)	Fingers	Fingers	Both eyelid cleanser and BS demonstrated efficacy in treating blepharitis; however, only the dedicated eyelid cleanser showed effectiveness in reducing inflammation on the ocular surface.
Garcia et al. (2018)[10]	42 subjects (22 M, 20 F) were divided into three groups.	Dedicated BS (Johnson's® No More Tears®)	1) Povidone-iodine (PI, Betadine) 2) Isopropyl alcohol (IA)	A sterile cotton-tipped swab	PI: A sterile cotton-tipped swab IA: Cotton pads	Dedicated BS, PI solution, and IA can all reduce eyelid bacterial load, but the group using baby shampoo showed the best performance in reducing bacterial load, and there were no discomfort symptoms.
Zarei-Ghanavati et al. (2021)[23]	40 patients with MGD (23 M, 17 F)	Tea tree oil (TTO) shampoo (EYESOL)	Regular eyelid shampoo (Johnson's® No More Tears®)	Cotton buds	Cotton buds	TTO shampoo was more effective in improving meibomian gland function and reducing symptoms.
Murphy et al. (2018)[58]	86 subjects (33 M, 36 F)	OcuSoft Lid Scrub Plus foam	1) Dr Organic Tea Tree Face Wash (TTFW) 2) OcuSoft Lid Scrub Plus (OLSP)	BlephEx™ microblepharoexfoliation device	1) Cotton pads 2) OLSP wipes	All methods demonstrated effectiveness and emphasized their potential therapeutic benefits in relieving symptoms and addressing the presence of Demode.
Murphy et al. (2020)[54]	48 university students	1) Blepharitis eyelid cleanser (OCuSOFT® Lid Scrub® PLUS foam). 2) Diluted BS (10% Johnson’ s® No More Tears ®)] 3) A tea-tree-based face wash (dr.organic®).	Cooled boiled water	Cotton pads	Cotton pads	These eyelid cleansing products were tested and found to improve subjective symptoms, but BS may potentially increase ocular surface inflammation.
Gao et al. (2007)[15]	11 patients with ocular Demodex (6 M, 5 F)	At the office) 50% TTO At home) tea tree (TT) shampoo	-	At the office) cotton tips At home) fingers	-	The TTO scrub effectively eradicates Demodex and improves subjective and objective symptoms.
Gao et al. (2012)[18]	24 patients with ocular itching and ocular Demodex (10 M, 14 F)	Chlortetracycline hydrochloride eye ointment (CHEO) and 5% tea tree oil ointment (TTOO)	-	Fingers	-	Daily lid massage with 5% TTOO demonstrates a significant correlation between the resolution of symptoms and the reduction of Demodex counts.
Wong et al. (2019)[50]	20 subjects (6 M, 14 F)	Blephadex™ Eyelid Wipes (Lunovus, LLC, Morris, Alabama USA) contain tea tree oil and also coconut oil	-	Wipes	-	There are no alterations in ocular characteristics were detected in the eyes of the normal healthy population after one month of daily usage of Blephadex™ Eyelid Wipes.
Epstein et al. (2021)[57]	50 consecutive patients with Demodex blepharitis	Terpinen-4-ol lid scrubs (Cliradex) + microblepharoexfoliation (MBE) (BlephEx)	Sham scrubs + MBE	Scrubs + MBE	Scrubs + MBE	The combination of in-office MBE treatments with either Cliradex T4O medicated lid scrubs or sham scrubs resulted in a significant statistical decrease in Demodex infestation levels.
Xie et al. (2019)[59]	15 subjects with dry-eye symptoms (4 M, 11 F)	Artificial tears + lid warming + Deep Cleaning Device (Ocuface Medical Co., Ltd., Guangzhou, China)	Artificial tears + lid warming	Deep Cleaning Device	-	The use of the innovative deep cleaning device for eyelid margin cleaning proves to be an effective treatment for individuals experiencing dry eye associated with MGD.
Kobayashi et al. (2016)[44]	10 subjects with dry eye associated with MGD and 10 healthy subjects	Eye Shampoo Long [ESL], MediProduct Co., Ltd., Tokyo, Japan	Eye Shampoo Long [ESL], MediProduct Co., Ltd., Tokyo, Japan	One hand or a piece of cotton	One hand or a piece of cotton	Eyelid hygiene maintenance with ESL demonstrated improvements in eyelid margins, alleviation of dry eye symptoms, and increased eyelash length in patients with MGD.
Liu and Gong (2021)[42]	52 patients with Demodex blepharitis	Okra eyelid patch (YourGa®; Shanghai YourGa Co., Ltd.)	TTO eye care patch (YourGa; Shanghai YourGa Co., Ltd.)	Eyelid patch	Eyelid patch	Okra eyelid patch effectively eradicates Demodex both in patients and in vitro, and its application is associated with reducing ocular discomfort, along with superior ocular tolerability.
Yang et al. (2021)[38]	48 patients with blepharitis	Hypochlorous acid	-	Cleansing wipes	-	The use of hypochlorous acid eye cleansing wipes to clean the eyelid margins for 1 week has a positive effect on different types of blepharitis and improves tear film stability.
Ergun et al. (2019)[16]	49 patients	3% TTO	3% TTO plus calendula oil, borage oil, vitamin E, vitamin B5 less than 5%	Cleansing gel	Cleansing gel	Both formulations demonstrated improvements in ocular surface parameters, with the cleansing gel group exhibiting a greater reduction in tear cytokines and Demodex count.

Blepharitis and BKC

Blepharitis and BKC usually require clinical and combined home eyelid cleaning, which can be converted to at-home cleaning with regular follow-up once the condition is stable. If there is a combination of Demodex infection and a large number of scales on the lid margin, in addition to regular cleaning, cleaning products with ingredients such as TTO, T4O, and okra can be used to assist in treatment. If there is no presence of Demodex and numerous eyelid scales, cleaners with moderate properties, such as baby shampoo and hypochlorous acid, would be sufficient to maintain eyelid hygiene.

Meibomian gland dysfunction and dry eye

The majority of dry-eye patients have associated MGD. Obstructive meibomian gland and meibomian gland atrophy can lead to ocular discomfort and symptoms of dry eye. Tanabe et al.[43] showed that regular eyelid cleaning resulted in significant improvement in most patients who reported symptoms and clinical dry eye assessments such as tear break-up time (TBUT), lid margin lissamine green staining scores, and meibomian gland repairment status.[62] Yin et al.[61] used a combination treatment regime of eyelid scrubbing and artificial lubricants. After one month, meibomian gland function improved, ocular discomfort was relieved, and eyelid hygiene recovered; thus, it can be considered an effective treatment for MGD.

Eyelid trauma

Keeping the lid margin clean after trauma is crucial to prevent the occurrence of infection and effectively prevent microorganisms such as bacteria from entering the eye and causing serious infection. The wounds are first fully irrigated with 0.9% sodium chloride solution, followed by disinfection of the patient with 0.5% iodophor under local anesthesia, scrubbing of the base and wound with 0.3% hydrogen peroxide solution, and finally rinsing the wound again with 0.9% sodium chloride solution.[63] The cleaning should be more thorough to remove bacteria, dirt, and foreign bodies from the wound to avoid affecting wound healing.

Perioperative eyelid cleaning

The incidence of ophthalmic surgical infections is not high. The bacteria in the eyelid and conjunctival sac are considered to be the most common cause of postoperative endophthalmitis. Peral et al.[64] used wipes containing antibacterial ingredients to wipe the eyelids before performing cataract surgery. The microorganisms on the eyelids and conjunctiva were significantly reduced, greatly preventing the occurrence of postoperative infections. Many experts have proposed eyelid cleaning as an important precaution before ophthalmic surgery.[65]

Eyelid cleaning for patients with skin lesions in systemic diseases

Systemic diseases such as scleroderma,[66] systemic lupus erythematosus,[67] Sjogren's syndrome,[68] psoriasis,[69] and vesiculobullous disorders[70] may cause damage to the health of eyelid skin. Thus, attention should be paid to the presence or absence of eyelid lesions when cleaning eyelids. In patients with autoimmune diseases such as Steven–Johnson syndrome, a large amount of oil-like secretion samples adhere to the eyelashes. Due to the burn-like appearance of the skin and mucosa of the disease, it is difficult to perform lid margin cleaning. It is usually necessary to cut off the eyelashes from the roots.[71] Patients start routine eyelid margin cleansing with hot compress to reduce the occurrence of MGD until the disease is in remission and the skin lesions heal.[70]

Adverse reactions

The use of at-home eyelid cleansers with antibacterial and mite-killing agents may cause discomfort in the eyes.[23] Excessive cleaning may sometimes induce or aggravate dry eyes. Some people are allergic to fragrances and other ingredients in baby shampoos; thus, their ocular surface is more sensitive.[72] When cleaning eyelids, products that may be allergic should be avoided. High concentrations of TTO and T4O inflame the ocular surface and should thus be administered by skillful medical personnel, also making it difficult to be used in the patient's home.[21]

Summary and Outlook

Eyelid cleaning plays an important role in maintaining ocular surface health and controlling symptoms in patients with blepharitis, MGD, and Demodex infection. For home cleaning, a low-concentration and low-irritation-causing detergent is often applied. In clinic eyelid cleaning, highly concentrated and stronger cleansers can be used by qualified professionals, as well as specialized tools that allow for deeper cleaning such as electric cleansers. These clinical cleaning procedures allow patients to achieve greater improvement. However, there is no clear boundary between the indications for eyelid cleaning at home or in the clinic. In addition, there is no specific guideline on the intensity of the procedure and duration of the eyelid cleaning procedure, as well as the treatment span and follow-up time. In the future, clear guidelines should be defined to guide patients on appropriate eyelid cleaning. In addition, more comfortable and efficient eyelid cleaners and tools can be developed to benefit patients both in the clinic and at home.

Financial support and sponsorship

This work was supported by Nature Science Foundation of Fujian (grant number 2020J01233). Key Clinical Specialty Discipline Construction Program of Fujian, P. R. C (Fujian Health Medicine and Politics [2022]884).

Conflicts of interest

There are no conflicts of interest.