Blepharitis Treatment
The cornerstone of blepharitis treatment is consistent daily eyelid hygiene, including warm compresses and gentle eyelid cleansing, which should be maintained long-term as blepharitis is typically a chronic condition with no definitive cure. 1
Step-wise Treatment Approach
First-line Treatment: Eyelid Hygiene (2-4 weeks)
- Apply warm compresses for 5-10 minutes once or twice daily
- Gently clean eyelid margins with diluted baby shampoo or commercial pet-safe eyelid cleanser
- Remove crusts by gently rubbing side to side along eyelid margins
- Consider commercial eyelid scrubs, which patients often prefer for convenience and ease of use 2
- For posterior blepharitis/meibomian gland dysfunction (MGD), add vertical eyelid massage to express meibomian glands
Second-line Treatment: Add Topical Antibiotics (if inadequate response to hygiene)
- Options include:
- A brief course of topical corticosteroids (such as loteprednol etabonate) may be considered for marked inflammation, but use with caution and monitor for corneal ulceration 1
Third-line Treatment: Oral Antibiotics (for persistent posterior blepharitis/MGD)
- Reserved for severe cases not responding to eyelid hygiene and topical treatments
- Tetracyclines (doxycycline, minocycline, tetracycline) work through both antimicrobial and anti-inflammatory mechanisms 1
- Macrolides (erythromycin, azithromycin) are alternatives for women of childbearing age and children 1
- Azithromycin dosing: 500mg daily for 3 days in three cycles with 7-day intervals, or 1g weekly for 3 weeks
- Erythromycin for children: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks
- Treatment duration: 1-3 months, then reassess 1
Important Clinical Considerations
Classification of Blepharitis
- Anterior blepharitis: Affects anterior lid margin and eyelashes (typically staphylococcal and/or seborrheic) 3
- Posterior blepharitis: Involves dysfunction of the meibomian glands 3
- Both types can coexist and one can lead to the other if untreated 4
Special Considerations
- Contraindications: Tetracyclines are contraindicated in pregnancy, nursing women, children under 8 years, and patients with hypersensitivity to tetracyclines 1
- Cautions:
- Avoid excessive pressure during eyelid massage, especially in patients with glaucoma 1
- Use care with patients with neurotrophic corneas to avoid epithelial injury 1
- Monitor for side effects of tetracyclines: photosensitization, GI upset, vaginitis, drug interactions 1
- Azithromycin has potential cardiac effects and a small increased risk of cardiovascular deaths in high-risk patients 1
Patient Education
- Emphasize that blepharitis is typically chronic with no definitive cure 1
- Stress the importance of continued long-term eyelid hygiene to control symptoms 1
- Advise patients to seek medical attention if there is a sudden increase in ocular pain or other concerning symptoms 1
Pre-surgical Considerations
- Address moderate to severe blepharitis before intraocular surgery to reduce the risk of endophthalmitis 1
Emerging Treatments
Recent research indicates that various compounds for managing lid margin diseases are in late stages of development 5. For posterior blepharitis/MGD specifically, in-office administration of heat therapy/thermal pulsation treatment may help clear obstructions in the meibomian glands and restore meibum secretions 5.