What is the treatment for blepharitis?

Treatment of Blepharitis

The cornerstone of blepharitis treatment is daily eyelid hygiene with warm compresses and eyelid cleansing, which significantly improves symptoms even though a complete cure is usually not possible. 1

Types of Blepharitis and Treatment Approach

Blepharitis can be categorized into:

• Anterior blepharitis: Affects the anterior lamella of the eyelid and eyelashes
• Posterior blepharitis: Affects the posterior lamella and involves meibomian gland dysfunction (MGD)

First-Line Treatment for All Types

1. Warm compresses:

   • Apply to eyelids for several minutes to soften adherent debris and warm meibomian secretions
   • Use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave
   • Important: Instruct patients to avoid temperatures that could burn the skin
   • Frequency: Once or twice daily at times convenient for the patient 1

2. Eyelid cleansing:

   • Gentle massage of eyelids
   • For anterior blepharitis: Rub eyelid margins side to side to remove crusting
   • For posterior blepharitis/MGD: Vertical eyelid massage to express meibomian glands
   • Options for cleaning:
     • Diluted baby shampoo
     • Commercially available eyelid cleaners
     • Hypochlorous acid 0.01% cleansers (strong antimicrobial effect)
   • Apply using pad, cotton ball, cotton swab, or clean fingertip 1

Additional Treatments Based on Severity and Type

For Moderate to Severe Anterior Blepharitis

• Topical antibiotics:
  • Antibiotic ointments (bacitracin, erythromycin) applied to eyelid margins once or more daily or at bedtime for a few weeks
  • Can be used intermittently with different medications to prevent resistance 1

For Posterior Blepharitis/MGD

• Artificial tears for associated dry eye symptoms 1
• Topical perfluorohexyloctane (newer treatment option) 1
• Topical anti-inflammatory agents (corticosteroids, cyclosporine) for marked inflammation 1

For Severe or Refractory Cases

• Oral antibiotics (particularly for MGD):
  • Tetracyclines (doxycycline, minocycline)
  • Note: Evidence for oral antibiotics is limited and they may cause adverse effects 2

For Demodex Blepharitis

• Antiparasitic medications:
  • Metronidazole
  • Ivermectin
  • Lotilaner (emerging therapy showing promise in clinical trials) 1, 3

In-Office Procedures for Persistent MGD

• Vectored thermal pulsation
• Microblepharoexfoliation 1

Important Clinical Considerations

1. Patient education is crucial:

   • Emphasize that blepharitis is typically chronic and requires ongoing management
   • Treatment aims to control symptoms rather than provide a cure 1

2. Safety considerations:

   • Assess patient's manual dexterity and ability to perform eyelid hygiene safely
   • Use caution in patients with neurotrophic corneas to avoid epithelial injury
   • Patients with advanced glaucoma should avoid aggressive lid pressure 1

3. Pre-surgical management:

   • Control moderate to severe blepharitis before intraocular surgery
   • Common blepharitis-associated pathogens (coagulase-negative Staphylococcus, S. aureus, Streptococcus) are implicated in postoperative endophthalmitis 1

4. Treatment persistence:

   • The optimal regimen often requires persistence and a trial-and-error approach
   • Symptoms typically recur when treatment is discontinued 1

5. Special populations:

   • Children with blepharitis may present with recurrent conjunctivitis, keratitis, neovascularization, and eyelid inflammation
   • Presentation can be asymmetric and confused with herpetic disease 1

By following this treatment algorithm and tailoring it to the specific type and severity of blepharitis, most patients will experience significant symptom improvement, though ongoing management is typically necessary for this chronic condition.