What is the treatment for blepharitis?

Treatment for Blepharitis

The first-line treatment for blepharitis is a combination of warm compresses (10-15 minutes, 3-4 times daily), eyelid hygiene, and gentle massage of the eyelids. 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 from lid margins
• Gentle massage: To express meibomian glands

Second-line Treatment

• Add topical antibiotics when there are 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

Fourth-line Treatment

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

Special Considerations

For Posterior Blepharitis/Meibomian Gland Dysfunction

• In-office heat therapy or thermal pulsation treatment may be beneficial to clear obstructions in the meibomian glands 3

For Severe or Unresponsive Cases

• Oral antibiotics may be considered:
  • Doxycycline: For persistent or recurrent infections (not recommended for children under 8 years) 1
  • Azithromycin: Alternative option, but use with caution due to potential cardiac risks 1

For Demodex Blepharitis

• Specific treatment may be required as Demodex infestation is responsible for more than two-thirds of all blepharitis cases in the US 4
• Lotilaner ophthalmic solution 0.25% has shown effectiveness in eradicating Demodex mites 5

Diagnostic Considerations

• Slit lamp examination should be performed to evaluate:
  • Lid margin abnormalities
  • Meibomian gland orifices
  • Conjunctival involvement
  • Corneal integrity 1
• Assess meibomian gland expression by applying pressure to the lower eyelids 1
• For Demodex blepharitis, look for collarettes (waste product of Demodex mites) at the base of eyelashes, which is pathognomonic 4

Prevention and Patient Education

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

When to Refer

Refer to a specialist for:

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

Common Pitfalls and Caveats

1. Failure to identify underlying conditions: Consider seborrheic dermatitis, rosacea, eczema, and thyroid dysfunction in patients with blepharitis 1
2. Inadequate duration of treatment: Blepharitis often requires long-term management 6
3. Overlooking Demodex infestation: This is a common cause of treatment-resistant blepharitis 4
4. Inconsistent eyelid hygiene: The mainstay of treatment needs to be continued long-term 6
5. Missing signs of malignancy: 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 1

Patients should be reassessed after 2-4 weeks to evaluate treatment response 1. The pathophysiology of blepharitis involves a complex interaction of factors including abnormal lid-margin secretions, microbial organisms, and abnormalities of the tear film, which may require tailored approaches based on the specific presentation 6.