What to do for bilateral eye corner redness and drainage worsening with erythromycin ointment?

Management of Bilateral Eye Corner Redness and Drainage Worsening with Erythromycin Ointment

The patient should discontinue erythromycin ointment and be evaluated for blepharitis with possible bacterial resistance or allergic reaction, requiring alternative treatment approaches. 1, 2

Diagnosis Considerations

The worsening of symptoms after starting erythromycin ointment suggests either:

1. Bacterial resistance - Erythromycin resistance is common when used as monotherapy 1
2. Allergic reaction - Local adverse reactions to erythromycin include peeling, dryness, itching, erythema, and eye irritation 2
3. Underlying condition not addressed - Such as:
   • Demodex mite infestation
   • Meibomian gland dysfunction
   • Seborrheic dermatitis
   • Ocular rosacea

Treatment Algorithm

First Steps (Immediate)

• Discontinue erythromycin ointment
• Begin warm compresses (10-15 minutes, 3-4 times daily) and eyelid hygiene 1
• Consider referral to ophthalmologist if symptoms are severe or persistent (>2 weeks) 1

Alternative Topical Treatment Options

1. For suspected bacterial infection with resistance:

   • Consider combination antibiotic/steroid preparation for moderate to severe cases 1
   • Alternative antibiotics such as bacitracin may be considered 1

2. For suspected Demodex mite infestation:

   • Tea tree oil-based lid scrubs 1
   • Consider topical ivermectin 3

3. For moderate to severe cases with inflammation:

   • Brief course of topical corticosteroids may help reduce inflammation 3
   • Use site-specific corticosteroids like loteprednol etabonate to minimize adverse effects 3

Systemic Treatment (For Severe or Refractory Cases)

• Oral tetracyclines (doxycycline, minocycline) may be effective for posterior blepharitis 3
  • Contraindicated in pregnancy, nursing women, and children under 8 years
• Oral azithromycin (500 mg per day for 3 days in three cycles with 7-day intervals) has shown good clinical improvement 3
  • Note: FDA warning about potential cardiac effects with oral azithromycin 3

Prevention of Recurrence

• Maintain good eyelid hygiene with regular cleansing
• Remove eye makeup completely before bed
• Discontinue contact lens wear until symptoms resolve
• Consider treating underlying conditions like rosacea or seborrheic dermatitis

Warning Signs Requiring Immediate Referral

• Visual changes
• Severe eyelid swelling
• Persistent symptoms despite treatment
• Suspected malignancy (chronic or atypical presentation) 1

Important Considerations

• Malignancy, particularly sebaceous carcinoma, can mimic chronic blepharitis and should be considered in cases that don't respond to appropriate therapy 1
• Bacterial resistance to erythromycin is common when used as monotherapy, which may explain the worsening symptoms 1
• The adverse reaction profile of erythromycin includes eye irritation, which could be contributing to the patient's symptoms 2