What is the treatment for blepharitis?

Blepharitis Treatment

The first-line treatment for blepharitis consists of warm compresses (10-15 minutes, 3-4 times daily) combined with eyelid hygiene and gentle massage, followed by topical antibiotics such as bacitracin or erythromycin ointment for signs of infection. 1

Treatment Algorithm

First-line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
• Eyelid hygiene: Carefully remove all scales and crusts
• Gentle eyelid massage: To express meibomian glands in posterior blepharitis

Second-line Treatment

• Topical antibiotics: For signs of infection or risk of secondary infection
  • Bacitracin ointment: Apply directly into the conjunctival sac 1-3 times daily 2
  • Erythromycin ointment: Apply 1-4 times daily for 7-10 days 1
  • For blepharitis: Spread the ointment uniformly over lid margins after cleaning 2

Third-line Treatment

• Combination antibiotic/steroid topical treatment: For moderate to severe cases 1

Fourth-line Treatment

• For persistent chalazia (>2 months) or large chalazia:
  • Consider intralesional steroid injection
  • Consider incision and curettage 1

Special Considerations for Different Types of Blepharitis

Anterior Blepharitis (affecting skin and lashes)

• Usually staphylococcal and/or seborrheic in nature
• Focus on eyelid hygiene with warm compresses, eyelid scrubs, and over-the-counter eyelid cleansers 3

Posterior Blepharitis/Meibomian Gland Dysfunction

• Requires warm compresses or in-office heat therapy/thermal pulsation treatment
• Aims to clear obstruction in meibomian glands and restore meibum secretions 3

Demodex Blepharitis

• Accounts for more than two-thirds of all blepharitis cases in the US 4
• Diagnosis: Look for collarettes (waste product of Demodex mites) at the base of eyelashes - this is pathognomonic 5, 4
• Treatment: Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy specifically for Demodex blepharitis 4

Monitoring and Follow-up

• Evaluate patients for:
  • Redness, swelling, crusting at lid margins
  • Discharge, eyelash abnormalities
  • Meibomian gland expression
  • Associated conditions (dry eye, rosacea) 1
• Follow-up in 2-4 weeks for moderate cases 1
• Reassess initial treatment after 2-4 weeks 1

Prevention of Recurrence

• Regular eyelid hygiene is essential for preventing recurrences 1
• Complete removal of eye makeup
• Treatment of underlying conditions (rosacea, seborrheic dermatitis)
• Discontinue contact lens wear until symptoms resolve 1

Important Cautions and Pitfalls

• Antibiotic resistance risk: Avoid inadequate application, premature discontinuation, or overuse of antibiotics 1
• Consider rotating antibiotics with different mechanisms of action if repeated courses are needed 1
• Watch for malignancy: Consider sebaceous carcinoma in cases of chronic or atypical blepharitis 1
• Medication contraindications:
  • Tetracyclines are contraindicated in pregnancy, nursing women, and children under 8 years 1
  • Oral azithromycin may lead to serious heart rhythm irregularities 1
• Pre-surgical consideration: Control moderate to severe blepharitis prior to intraocular surgery to reduce the risk of postoperative endophthalmitis 1

When to Refer to an Ophthalmologist

• Persistent styes (>2 weeks)
• Styes that develop into chalazia
• Suspected MRSA infections
• Visual changes
• Severe eyelid swelling
• Immunocompromised patients 1

Remember that blepharitis is often a chronic condition requiring long-term management rather than a condition that can be permanently cured 6. Patient education about the potentially chronic nature of the condition is crucial for treatment adherence and successful management 1.