What is the treatment plan for blepharitis?

Treatment Plan for Blepharitis

The treatment of blepharitis should follow a stepwise approach, beginning with warm compresses, eyelid hygiene, and gentle massage as first-line therapy, followed by topical antibiotics for signs of infection, and escalating to combination antibiotic/steroid treatments for moderate to severe cases. 1

Classification and Diagnosis

Blepharitis can be classified as:

• Anterior blepharitis: Affects the anterior lid margin and eyelashes
• Posterior blepharitis: Involves dysfunction of the meibomian glands (MGD)

Diagnostic evaluation should include:

• Slit lamp examination to evaluate lid margin abnormalities, meibomian gland orifices, conjunctival involvement, and corneal integrity
• Assessment of meibomian gland secretions by applying pressure to the lower eyelids 1
• Consideration of underlying conditions such as seborrheic dermatitis, rosacea, eczema, and thyroid dysfunction 1

Treatment Algorithm

First-Line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily
• Eyelid hygiene: Regular cleansing of eyelid margins
• Gentle massage: To express meibomian glands 1, 2

Second-Line Treatment

• Topical antibiotics: Apply bacitracin or erythromycin ointment directly to affected eye(s)
  • Erythromycin ointment: Apply approximately 1 cm in length up to six times daily depending on severity
  • Treatment duration: Typically a few weeks, guided by symptom response 1
• Tea tree oil: Consider if Demodex mites are present 1

Third-Line Treatment

• Combination antibiotic/steroid topical treatment for moderate to severe cases
  • Caution: Monitor for increased intraocular pressure and cataract formation
  • Topical steroids should be used short-term 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
  • Doxycycline is not recommended for children under 8 years 1
  • Oral erythromycin for pediatric cases: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks
  • Alternative pediatric regimen: Azithromycin 5 mg/kg daily for 2 months (use with caution due to potential cardiac risks) 1

For Persistent Chalazia (>2 months)

• Consider intralesional steroid injection
• Consider incision and curettage for large chalazia 1

Additional Therapeutic Considerations

Artificial Tears

• Preservative-containing artificial tears: Limit to ≤4 times/day
• Preservative-free options: Recommended for frequent use (>4 times/day) 1
• Avoid over-the-counter eye drops with preservatives or vasoconstricting agents 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
• Eye care hygiene:
  • Complete removal of eye makeup before sleeping
  • Discontinue contact lens wear until symptoms resolve 1

Follow-up and Monitoring

• Patient education on the chronic nature of the condition
• Reassessment after 2-4 weeks to evaluate treatment response 1

Referral Criteria

Refer to a specialist if:

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

Consider biopsy for:

• 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 3, 4
• Complete cure is not possible in most cases; focus on symptom management 4
• Subjective symptoms may persist even when clinical signs have improved 5
• Treatment effectiveness should be evaluated based on both symptom relief and clinical improvement 5
• Underlying conditions (seborrheic dermatitis, rosacea) should be addressed for optimal management 1, 3

The most recent evidence supports a comprehensive approach targeting both the infectious and inflammatory components of blepharitis, with eyelid hygiene remaining the cornerstone of treatment 1, 2.