pustules underneath the upper eyelid

[patch117]

I have been suffering for years with severe eye irritation and swollen, red eyelids.  I have been dealing with this for over 10 years. For the last couple of years, every few weeks or so, it would feel like there was an eyelash underneath my upper eyelid.  I finally reverse flipped the eyelid open and saw there was 5 or 6 small pustules on the underside of the lid.  The lid is red and swollen and it hurts.  I have been diagnosed with ocular rosacea and blepharitis in the past.  The only thing that has worked is doxycycline 50mg 1x/day.  My Ophthalmologist and Dermatologist don’t want me taking doxy long term (why I don’t know since it works) and put me on Oracea, which doesn’t do the trick.  Does anyone know what these pustules are?  How should they be treated?  They seem to affect tear production since I need to use a lot of artificial tears during these flare ups.  The eyelids, both top and bottom, are red rimmed and the uppers have a band of red from the lashes to about ½ way up.  I can’t find anything similar online.  This is destroying my self-confidence, social life and career. I'm 50 and these problems started about 10 years ago.  Help please

[John C Hagan III, MD, FACS, FAAO]

Keep at it. Help is out there.
JCH MD

[patch117]

Thank you very much for your quick, thorough and thoughtful response.  I plan on taking your advice and working through each of the items you discussed. I appreciate the support.

[John C Hagan III, MD, FACS, FAAO]

It is not at all likely that what you're seeing are "pustules" which are transient and go away in a few days to a week. Much more likely you are seeing either conjunctival "concretions" which are whitish like collections of an oil like substance. Usually they are covered with tissue and can be seen but not felt.

I would suggest you travel to the best available respected ophthalmology referral center and see an ophthalmologist that specializes in "external eye disease".  Most medical school ophthalmology departments have such an individual. While there discuss with him/her going on long term restasis and using a topical steroid such as lotemax for the first couple of weeks to reduce the stinging you likely will have.  The use of restasis for long term eye for surface eye inflammation is a very promising new use.

Another very promiscing drug that might benefit you is Azasite which is an eyedrop that has emerged as the favorite for resistant and chronic blepharitis.

There is some evidence that taking Omega-3 in the form of enteric coated fishoil (high quality) 2 or 3 pills/day over a 4-6 month period may have a favorable effect on both the eye dryness and the toxicity of the oil that builds in the eyelid oil glands. Lastly ask the external disease specialist about tear duct plugs for several months. If it works well might consider permanent closure of lower openings.

Keep working you may not be able to be cured but you likely can be helped.

JCH MD