What is the treatment for blepharitis?

Treatment of Blepharitis

The first-line treatment for blepharitis consists of warm compresses (10-15 minutes, 3-4 times daily), eyelid hygiene with gentle massage, and removal of all scales and crusts from the lid margins. 1

Step-wise Treatment Approach

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

Second-line Treatment

• Add 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 approximately 1 cm in length directly to the affected eye(s) up to six times daily depending on severity 1

Third-line Treatment

• Consider combination antibiotic/steroid topical treatment for moderate to severe cases 1
• Duration typically a few weeks, guided by symptom response

Fourth-line Treatment

• Oral antibiotics for severe or unresponsive cases:
  • Oral erythromycin: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 1
  • Alternative: Azithromycin 5 mg/kg daily for 2 months (use with caution due to potential cardiac risks) 1
  • Doxycycline may be considered for moderate-severe cases 1

Special Considerations

Demodex Blepharitis

• Present in approximately two-thirds of all blepharitis cases in the US 3
• Diagnosis: Presence of collarettes (waste product of Demodex mites) at the base of eyelashes is pathognomonic 3
• Treatment may require specific acaricide medication 4
• Recent evidence suggests lotilaner ophthalmic solution 0.25% is effective in eradicating Demodex mites 5

Posterior Blepharitis/Meibomian Gland Dysfunction (MGD)

• Requires thermal therapy to clear obstructions in meibomian glands 6
• Artificial tears without preservatives can help with tear film instability 1

Prevention and Patient Education

• Good eyelid hygiene and complete removal of eye makeup before sleeping 1
• Dietary modifications (such as a Mediterranean diet) may help prevent recurrence 1
• Discontinue contact lens wear until symptoms resolve 1
• Educate patients on the chronic nature of the condition 1

Follow-up and Referral

• Reassess after 2-4 weeks to evaluate treatment response 1
• Refer to a specialist for:
  • Visual changes
  • Corneal involvement
  • Severe eyelid swelling unresponsive to initial treatment
  • Suspected malignancy
  • Cicatricial changes in the conjunctiva 1

Cautions and Pitfalls

• Avoid undertreating: Blepharitis often requires consistent, long-term management
• Monitor for complications: When using topical steroids, watch for increased intraocular pressure and cataract formation 1
• Consider underlying conditions: Seborrheic dermatitis, rosacea, eczema, and thyroid dysfunction can contribute to blepharitis 1
• Biopsy warning signs: Consider biopsy for marked asymmetry between eyes, resistance to standard therapy, unifocal recurrent chalazia, loss of normal eyelid margin anatomy, or focal lash loss 1