What is the treatment for blepharitis?

Treatment of Blepharitis

The first-line treatment for blepharitis is warm compresses for 10-15 minutes 3-4 times daily, combined with eyelid hygiene and gentle massage, followed by topical antibiotics for signs of infection. 1

Step-wise Treatment Approach

First-line Treatment

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

Second-line Treatment

• Topical antibiotics: Apply directly to lid margins
  • Bacitracin ointment: Apply directly into conjunctival sac 1-3 times daily 2
  • Erythromycin ointment: Apply approximately 1 cm in length directly to affected eye(s) up to six times daily, depending on severity 1

Third-line Treatment

• Combination antibiotic/steroid topical treatment for moderate to severe cases 1
  • Note: Topical steroids should be used short-term only unless the patient has autoimmune disease or moderate to severe dry eye disease 1

Fourth-line Treatment

• Oral antibiotics for severe or unresponsive cases:
  • Tetracycline antibiotics (doxycycline)
  • Oral macrolides
  • Oral erythromycin (for pediatric patients: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks)
  • Azithromycin (5 mg/kg daily for 2 months) with caution due to potential cardiac risks 1

Special Considerations

For Demodex-Related Blepharitis

• Tea tree oil treatment is recommended when Demodex mites are present 1, 3

For Posterior Blepharitis/MGD

• Heat therapy/thermal pulsation treatment to clear meibomian gland obstruction 4

Adjunctive Measures

Artificial Tears

• Preservative-containing tears: Limit to ≤4 times/day
• Preservative-free options: Recommended for frequent use (>4 times/day) 1

Lifestyle Modifications

• Dietary modifications: Mediterranean diet may be beneficial 1
• Environmental considerations:
  • Avoid excess dryness, wind, and air-conditioned environments
  • Increase blinking frequency (>10 times/minute) when using computers or watching TV 1
• Complete removal of eye makeup before sleeping 1
• Avoid over-the-counter eye drops with preservatives or vasoconstricting agents 1

Monitoring and Follow-up

• Reassess after 2-4 weeks to evaluate treatment response 1
• Patient education on the potentially chronic nature of the condition is essential 1

When to Refer to a Specialist

Refer patients with:

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

Biopsy Considerations

Consider biopsy for cases with:

• Marked asymmetry between eyes
• Resistance to standard therapy
• Unifocal recurrent chalazia
• Loss of normal eyelid margin anatomy
• Focal lash loss (madarosis) 1

Common Pitfalls and Caveats

• Blepharitis is often chronic and requires long-term management 5
• Subjective symptoms may persist even when clinical signs improve 5
• Underlying conditions such as seborrheic dermatitis, rosacea, eczema, and thyroid dysfunction should be identified and treated 1
• Doxycycline is not recommended for children under 8 years 1
• Monitor for increased intraocular pressure and cataract formation when using topical steroids 1

The management of blepharitis requires a systematic approach addressing both infectious and inflammatory components of the disease. While recent clinical trials support the use of antibiotics and topical corticosteroids 5, the cornerstone of treatment remains consistent eyelid hygiene and warm compresses 1, 4, 6.