Treatment for Chronic Blepharitis
The first-line treatment for chronic blepharitis consists of warm compresses (10-15 minutes, 3-4 times daily), eyelid hygiene with gentle massage, and may require topical antibiotics such as bacitracin or erythromycin ointment applied directly to the lid margins 1-3 times daily. 1, 2
Treatment Algorithm
First-line Treatment
- Warm compresses: Apply for 10-15 minutes, 3-4 times daily
- Helps soften adherent debris and warm meibomian secretions
- Eyelid hygiene:
- Carefully remove all scales and crusts
- Use hypochlorous acid (0.01%) cleaners for anterior blepharitis
- Perform vertical eyelid massage to express meibomian secretions for posterior blepharitis/MGD
- Artificial tears: Non-preserved artificial tears for tear film instability in posterior blepharitis
Second-line Treatment
- Topical antibiotics: Apply directly to lid margins 1-3 times daily 1, 2
- Bacitracin ointment
- Erythromycin ointment
- Indicated when signs of infection are present or risk of secondary infection exists
Third-line Treatment
- Combination antibiotic/steroid topical treatment for moderate to severe cases 1
- Brief courses only
- Monitor for increased intraocular pressure and cataract formation
Fourth-line Treatment
- Oral antibiotics for moderate-severe cases unresponsive to topical therapy 1
- Doxycycline
- Azithromycin (use with caution due to potential cardiac risks)
- Intralesional steroid injection or incision and curettage for persistent (>2 months) or large chalazia 1
Special Considerations
Diagnosis
- Perform slit lamp examination to evaluate:
- Lid margin abnormalities
- Meibomian gland orifices
- Conjunctival involvement
- Corneal integrity
- Assess meibomian gland expression by applying pressure to lower eyelids
- Consider Demodex infestation through microscopic examination of epilated eyelashes 1
Warning Signs Requiring Specialist Referral
- Chronic unresponsive blepharitis, especially when only one eye is involved
- Atypical eyelid-margin inflammation
- Marked asymmetry between eyes
- Nodular mass
- Loss of normal eyelid margin anatomy
- Focal lash loss (madarosis)
- Visual changes or corneal involvement 1
Associated Conditions
- Consider underlying conditions such as:
- Seborrheic dermatitis
- Rosacea
- Eczema
- Thyroid dysfunction 1
Prevention and Patient Education
- Complete removal of eye makeup before sleeping
- Dietary modifications (Mediterranean diet may help)
- Discontinue contact lens wear until symptoms resolve
- Educate patients on the chronic nature of the condition 1
Follow-up
- Reassess treatment response after 2-4 weeks
- Adjust therapy based on response
- Reassess control of eyelid inflammation prior to any eye surgery 1
Important Caveats
- Blepharitis is often chronic with no definitive cure 3, 4
- Subjective symptoms may persist even when clinical signs improve 3
- The evidence for oral antibiotics in chronic blepharitis is very limited and of very low certainty 5
- Topical steroids should be used with caution and for short durations only 1
- Always consider malignancy (especially sebaceous carcinoma) in cases of chronic or atypical blepharitis unresponsive to standard therapy 1