What is the management approach for blepharitis?

Management of Blepharitis

The cornerstone of blepharitis management is daily warm compresses and eyelid cleansing, which should be continued long-term as complete cure is usually not possible. 1

Classification

• Anterior blepharitis: affects eyelid skin, base of eyelashes, and follicles 1
• Posterior blepharitis: affects meibomian glands (also known as Meibomian Gland Dysfunction or MGD) 1

First-Line Treatment

Warm Compresses

• Apply to eyelids for several minutes to soften adherent scales and warm meibomian secretions 2
• Can be accomplished using hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag heated in microwave 2
• Should be performed once or twice daily at a time convenient for the patient 2
• Important to avoid compresses that are too hot to prevent skin burns 2

Eyelid Cleansing

• Brief, gentle massage of the eyelids to remove debris 2
• Options include:
  • Diluted baby shampoo on a pad, cotton ball, cotton swab, or clean fingertip 2
  • Commercially available eyelid cleaners 2
  • Hypochlorous acid 0.01% eye cleaners (strong antimicrobial effect for both anterior and posterior blepharitis) 2
• For posterior blepharitis/MGD: vertical eyelid massage to express meibomian secretions 2
• Rubbing eyelid margins from side to side removes crusting from eyelashes 2
• Should be performed daily or several times weekly 2

Second-Line Treatment

Topical Antibiotics

• Consider when first-line measures provide inadequate relief or when there are signs of bacterial infection 1
• Options include:
  • Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks 2
  • Should be used intermittently with different medications to prevent development of resistant organisms 2

Topical Anti-inflammatory Agents

• May be helpful in patients with marked inflammation 3
• Options include topical corticosteroids and cyclosporine 2

Advanced Treatment Options

For Persistent or Severe Cases

• Topical perfluorohexyloctane (FDA approved in 2023) to prevent tear evaporation and improve symptoms in patients with associated dry eye disease 2
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 1
• Selenium sulfide has been explored for use in MGD to break disulfide bonds, potentially unblocking meibomian gland orifices and decreasing meibum viscosity 2

Special Considerations

Pre-surgical Management

• Consider addressing moderate to severe blepharitis with topical antibiotics and eyelid hygiene prior to intraocular surgical procedures 2
• Common causative microorganisms of postoperative endophthalmitis include ocular surface pathogens associated with blepharitis (coagulase-negative Staphylococcus, S. aureus, and Streptococcus species) 2

Cautions

• Patients with neurotrophic corneas need proper counseling to avoid injury to corneal epithelium during eyelid cleansing 2
• Frequent manipulation of the eyelid may lead to mechanically induced irritation 2
• Patients with advanced glaucoma or history of glaucoma filtering procedure should avoid aggressive pressure on the eyelids 2
• Long-term antibiotic use may lead to development of resistant organisms 2, 1

Patient Education

• Blepharitis is typically chronic and requires ongoing management 1
• Symptoms often recur when treatment is discontinued 2
• Frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment 2

Treatment Algorithm

1. Begin with warm compresses and eyelid hygiene for 2-4 weeks 1
2. If inadequate response, add topical antibiotic ointment 1
3. For severe or resistant cases, consider advanced treatment options 1
4. Maintain long-term eyelid hygiene to control symptoms 1