What is the treatment for blepharitis?

Treatment of Blepharitis

The treatment for blepharitis requires a step-wise approach, beginning with warm compresses, eyelid hygiene with massage, and progressing to topical antibiotics and anti-inflammatory agents for more severe cases, as recommended by the American Academy of Ophthalmology. 1

First-Line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily 1
• Eyelid hygiene: Clean eyelids to remove scales and crusts 1
• Gentle eyelid massage: Helps express meibomian glands 1

When applying bacitracin ophthalmic ointment, all scales and crusts should be carefully removed first, then the ointment should be spread uniformly over the lid margins. The ointment can be applied directly into the conjunctival sac 1 to 3 times daily. 2

Second-Line Treatment

For cases that don't respond adequately to first-line measures:

• Topical antibiotics: Bacitracin or erythromycin ointment for signs of infection 1
  • Erythromycin ointment: Apply approximately 1 cm in length directly to affected eye(s), up to six times daily depending on severity 1
  • Treatment duration typically lasts a few weeks, guided by symptom response 1

Third-Line Treatment

For moderate to severe cases:

• Combination antibiotic/steroid topical treatment 1
  • These should be used with careful monitoring for increased intraocular pressure and cataract formation 1

Fourth-Line Treatment

For severe or unresponsive cases:

• Oral antibiotics:
  • Erythromycin (for pediatric cases: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks) 1
  • Doxycycline or azithromycin (for adults) 1
  • Azithromycin alternative regimen: 5 mg/kg daily for 2 months (use with caution due to potential cardiac risks) 1

Special Considerations for Demodex Blepharitis

Demodex infestation is responsible for more than two-thirds of all blepharitis cases in the United States 3. Treatment options include:

• Acaricide medication for cases with pathogenetically relevant demodicosis 4
• Lotilaner ophthalmic solution 0.25% has shown effectiveness in eradicating Demodex mites in one-half to two-thirds of patients with continued benefits through 1 year of follow-up 3, 5

Diagnosis and Evaluation

• Slit lamp examination: To evaluate lid margin abnormalities, meibomian gland orifices, conjunctival involvement, and corneal integrity 1
• Meibomian gland expression: Apply pressure to lower eyelids to evaluate secretion quality 1
• Demodex evaluation: Microscopic examination of epilated eyelashes if infestation is suspected 1
• Collarettes at the base of eyelashes are pathognomonic for Demodex blepharitis 3, 5

Prevention and Patient Education

• Practice good eyelid hygiene
• Complete removal of eye makeup before sleeping
• Consider dietary modifications (such as a Mediterranean diet) 1
• Discontinue contact lens wear until symptoms resolve 1
• Educate patients on the potentially chronic nature of the condition 1

When to Refer to a Specialist

Referral is recommended for cases with:

• Visual changes
• Corneal involvement
• Severe eyelid swelling unresponsive to initial treatment
• Suspected malignancy
• Cicatricial changes in the conjunctiva 1

Follow-up

Patients should be reassessed after 2-4 weeks to evaluate treatment response 1

Pitfalls and Caveats

• Blepharitis is often chronic and requires long-term management
• Underlying conditions such as seborrheic dermatitis, rosacea, eczema, and thyroid dysfunction should be considered and treated 1
• Consider biopsy for cases with marked asymmetry between eyes, resistance to standard therapy, unifocal recurrent chalazia, loss of normal eyelid margin anatomy, or focal lash loss (madarosis) 1
• Topical steroids should be used with caution due to risks of increased intraocular pressure and cataract formation 1