Treatment of Blepharitis
The cornerstone treatment for blepharitis is consistent daily eyelid hygiene, including warm compresses and gentle eyelid cleansing, with topical antibiotics such as bacitracin or erythromycin ointment added for inadequate response after 2-4 weeks. 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 eyelid cleanser
- Remove crusts by gently rubbing side to side along eyelid margins
- For blepharitis, all scales and crusts should be carefully removed before applying any medication 1, 2
Second-line Treatment: Add Topical Antibiotics
- If symptoms persist after 2-4 weeks of eyelid hygiene, add topical antibiotics:
Third-line Treatment: Consider Oral Antibiotics
- Reserved for severe, persistent posterior blepharitis or meibomian gland dysfunction (MGD) not responding to above measures 1
- Options include:
- Tetracyclines (doxycycline, minocycline, tetracycline) - work through both antimicrobial and anti-inflammatory mechanisms
- Macrolides (erythromycin, azithromycin) - alternative for women of childbearing age and children
- Azithromycin: 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
Types of Blepharitis and Specific Considerations
Anterior Blepharitis
- Affects the anterior lamella of the eyelid and eyelashes
- Often staphylococcal and/or seborrheic in nature 3
- Responds well to eyelid hygiene and topical antibiotics 4
Posterior Blepharitis/Meibomian Gland Dysfunction (MGD)
- Affects the posterior lamella of the eyelid and involves inflammation of the meibomian glands
- May require more aggressive treatment with warm compresses and oral antibiotics 4, 5
- Consider thermal pulsation treatment to clear obstructions in meibomian glands 4
Demodex Blepharitis
- Caused by Demodex mite infestation (accounts for >2/3 of all blepharitis cases in the US) 6
- Diagnosed by presence of collarettes at the base of eyelashes
- Recently approved treatment: lotilaner ophthalmic solution 0.25% 6
Important Clinical Considerations
Duration of Treatment
- Blepharitis is typically chronic with no definitive cure
- Eyelid hygiene must be continued long-term to control symptoms 1
- Oral antibiotics, when needed, typically require 1-3 months of treatment 1
Cautions and Contraindications
- Tetracyclines are contraindicated in pregnancy, nursing women, children under 8 years, and patients with hypersensitivity to tetracyclines 1
- Avoid excessive pressure during eyelid massage, especially in patients with glaucoma 1
- Patients with neurotrophic corneas need careful counseling to avoid epithelial injury 1
- Brief courses of topical corticosteroids may be considered for marked inflammation, but use with caution and monitor for corneal ulceration 1
Potential Side Effects
- Tetracyclines: photosensitization, gastrointestinal upset, vaginitis, drug interactions, rare cases of pseudotumor cerebri 1
- Azithromycin: potential cardiac effects and small but absolute increase in cardiovascular deaths, especially in patients with high baseline cardiovascular risk 1
Clinical Pearls
- Addressing moderate to severe blepharitis before intraocular surgery can reduce the risk of endophthalmitis 1
- Anterior blepharitis, if not treated, can lead to meibomian gland disease, and vice versa 5
- Blepharitis can be associated with systemic conditions like dermatitis, rosacea, and eczema 3, 5
- Patients should be instructed to take appropriate measures to avoid gross contamination of antibiotic ointment when applying directly to the infected eye 2