What are the treatment options for blepharitis?

Management of Blepharitis

The first-line treatment for blepharitis consists of warm compresses (10-15 minutes, 3-4 times daily), eyelid hygiene with gentle cleansing, and eyelid massage to express meibomian gland secretions. 1

Types of Blepharitis and Initial Assessment

Blepharitis can be categorized into:

• Anterior blepharitis: Affects the anterior lamella of the eyelid and eyelashes
• Posterior blepharitis: Affects the posterior lamella and involves inflammation of meibomian glands
• Mixed blepharitis: Combination of both anterior and posterior features
• Demodex blepharitis: Caused by Demodex mites, identified by collarettes at the base of eyelashes 2

Treatment Algorithm

First-Line Treatment (All Types of Blepharitis)

1. Warm compresses: Apply for 10-15 minutes, 3-4 times daily

   • Helps liquefy thickened sebum
   • Promotes drainage
   • Reduces inflammation 1

2. Eyelid hygiene:

   • Gently cleanse eyelid margins with clean pad, cotton ball, cotton swab, or fingertip
   • Focus on removing crusting from eyelashes for anterior blepharitis
   • Include vertical eyelid massage for posterior blepharitis to express meibomian gland secretions 1

3. Topical antibiotics:

   • Apply bacitracin or erythromycin ointment to eyelid margins once or more daily for 5-7 days
   • Decreases bacterial load on eyelid margin 1

Second-Line Treatment (For Persistent Cases)

1. Combination antibiotic/steroid topical treatment for moderate to severe cases 1

   • Short-term use of topical corticosteroids for marked inflammation
   • Cyclosporine may be beneficial in some cases

2. Oral antibiotics for persistent posterior blepharitis/MGD:

   • Doxycycline, minocycline, or tetracycline with tapered dosing after improvement
   • Important caution: Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years 1
   • May cause photosensitization, gastrointestinal upset
   • Oral azithromycin may lead to serious heart rhythm irregularities 1

Specific Treatments for Different Types

For Posterior Blepharitis/MGD

• In-office heat therapy/thermal pulsation treatment to clear meibomian gland obstruction 3
• Vectored thermal pulsation and microblepharoexfoliation procedures 1
• Topical perfluorohexyloctane to prevent tear evaporation 1

For Demodex Blepharitis

• Lotilaner ophthalmic solution 0.25% has shown promise in clinical trials for eradicating Demodex mites 2

Third-Line Treatment (For Persistent Chalazia)

• Intralesional steroid injection or incision and curettage for persistent (>2 months) or large chalazia 1

Ongoing Management and Prevention

1. Continue regular eyelid hygiene even after resolution to prevent recurrence 1
2. Remove eye makeup completely and consider replacing contact lenses and cases after resolution 1
3. Treat underlying conditions like dermatitis, rosacea, or eczema that may contribute to blepharitis 4
4. Discontinue contact lens wear until symptoms resolve 1

When to Refer to an Ophthalmologist

Refer patients with:

• Persistent symptoms (>2 weeks)
• Development of chalazia
• Suspected MRSA infections
• Visual changes
• Severe eyelid swelling
• Immunocompromised status 1

Special Considerations

• Ensure patients have adequate manual dexterity to perform eyelid hygiene safely
• Patients with advanced glaucoma should avoid aggressive lid pressure
• Patients with neurotrophic corneas need special care to avoid corneal epithelial injury
• Control moderate to severe blepharitis prior to intraocular surgery to reduce risk of postoperative endophthalmitis 1

Treatment Pitfalls to Avoid

1. Underestimating chronicity: Blepharitis is typically chronic and requires long-term management 4
2. Inadequate patient education: Patients need to understand the potentially chronic nature of the condition and importance of continued hygiene measures 1
3. Overuse of steroids: While effective for inflammation, long-term use can lead to complications
4. Neglecting underlying conditions: Failing to address associated conditions like rosacea or seborrheic dermatitis 4
5. Inappropriate antibiotic use: Using oral antibiotics when topical would suffice, or not considering contraindications

Remember that blepharitis management often requires a combination of approaches tailored to the specific type and severity of the condition, with eyelid hygiene forming the cornerstone of any treatment regimen 5.