What is the treatment for blepharitis?

Treatment for Blepharitis

The cornerstone of blepharitis treatment is consistent daily eyelid hygiene, including warm compresses, gentle eyelid cleansing, and vertical eyelid massage to express meibomian glands, which should be maintained long-term as blepharitis is typically chronic with no definitive cure. 1

Step-wise Treatment Approach

First-line Treatment: Eyelid Hygiene

1. Warm compresses

   • Apply for 5-10 minutes once or twice daily 2, 1
   • Can use hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave 1
   • Avoid temperatures that could burn the skin

2. Eyelid cleansing

   • Options include:
     • Diluted baby shampoo
     • Commercial eyelid cleaners
     • Hypochlorous acid 0.01% cleansers 1
   • Technique:
     • For anterior blepharitis: Rub eyelid margins side to side to remove crusting from eyelashes 2
     • For posterior blepharitis/MGD: Perform vertical eyelid massage to express meibomian glands 1
   • Frequency: Daily or several times weekly as a long-term maintenance strategy 2

Second-line Treatment (if inadequate response after 2-4 weeks)

1. Topical antibiotics
   • Options:
     • Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks 2
     • Topical azithromycin 1, 3
     • Loteprednol etabonate 0.5%/tobramycin 0.3% suspension (safer than dexamethasone due to less risk of IOP rise) 2

Third-line Treatment (for persistent posterior blepharitis/MGD)

1. Oral antibiotics

   • Tetracyclines (doxycycline, minocycline, tetracycline)
     • Low-dose doxycycline (20mg twice daily) may have fewer side effects while maintaining efficacy 1
     • Treatment duration: 1-3 months, then reassess 1
   • For women of childbearing age and children:
     • Macrolides (erythromycin, azithromycin) 1
     • Azithromycin: 500mg daily for 3 days in three cycles with 7-day intervals, or 1g weekly for 3 weeks 1
     • Erythromycin for children: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 1

2. Adjunctive therapy for marked inflammation

   • Short-term topical corticosteroids 1
   • Longer-term topical cyclosporine 1
   • Topical perfluorohexyloctane (FDA approved in 2023) 2, 1

Treatment Based on Blepharitis Type

Anterior Blepharitis

• Focus on removing crusts from eyelashes by rubbing side to side 1
• Topical antibiotics if bacterial component is significant 4

Posterior Blepharitis/MGD

• Emphasis on warm compresses and vertical eyelid massage to express meibomian glands 1
• Consider in-office heat therapy/thermal pulsation treatment for severe cases 4

Important Precautions and Patient Education

• Chronic condition: Inform patients that blepharitis is typically chronic with no definitive cure and that eyelid hygiene must be continued long-term to control symptoms 1

• Safety considerations:

  • Patients with advanced glaucoma should avoid aggressive pressure during eyelid massage 2, 1
  • Patients with neurotrophic corneas need careful counseling to avoid epithelial injury 2, 1
  • Eyelid cleaning can be dangerous if the patient lacks manual dexterity or necessary skill 2

• Medication precautions:

  • Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years 1
  • Monitor for side effects of tetracyclines: photosensitization, GI upset, vaginitis, drug interactions 1
  • Azithromycin has concerns about potential cardiac effects, especially in patients with high cardiovascular risk 1

• Surgical considerations: Address moderate to severe blepharitis before intraocular surgery to reduce endophthalmitis risk 1

Treatment Efficacy and Considerations

While various commercial eyelid scrubs are available and may be preferred by patients for convenience 5, there is a lack of robust evidence to support routine recommendation of specific eyelid wipes over other cleaning methods 2. Long-term costs and potential adverse effects should be considered when selecting treatment options.