What is the management approach for blepharitis?

Management of Blepharitis

The cornerstone of blepharitis management is daily eyelid hygiene with warm compresses and eyelid cleansing, which should be maintained long-term as the condition is typically chronic and requires ongoing management. 1, 2

First-Line Treatment Approach

• Apply warm compresses to the eyelids for several minutes to soften adherent crusts and scales and/or warm the meibomian secretions, using hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag 1, 2
• Perform eyelid cleansing by gentle massage of the eyelids, which can be accomplished by having the patient gently rub the base of the eyelashes using either diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip 1, 2
• Use hypochlorous acid 0.01% eye cleaners which have strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• For posterior blepharitis/Meibomian Gland Dysfunction (MGD), perform vertical eyelid massage to express meibomian secretions 1, 2
• Implement once or twice-daily warm compresses and massage, at a time most convenient for the patient 1

Important Considerations for First-Line Treatment

• Avoid using compresses that are too hot to prevent skin burns 1, 2
• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium 1
• Patients with advanced glaucoma should be advised not to place pressure on the lids aggressively as it may increase eye pressure 1
• Frequent manipulation of the eyelid may lead to mechanically induced irritation 1
• Patients should understand that treatment may be required long-term, as symptoms often recur when treatment is discontinued 1, 2

Second-Line Treatment Options

• If inadequate response to eyelid hygiene after 2-4 weeks, add topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily for a few weeks 1, 2
• Use topical antibiotics intermittently with different medications to prevent development of resistant organisms 1, 2
• Consider topical perfluorohexyloctane (FDA approved in 2023) which prevents tear evaporation and improves symptoms in patients with associated dry eye disease 1, 2
• Selenium sulfide may help unblock meibomian gland orifices and decrease meibum viscosity in MGD patients 1

For Persistent or Severe Cases

• Consider in-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 2
• For Demodex blepharitis, which affects approximately 25 million Americans, consider acaricide medication 3, 4
• Recent clinical trials suggest lotilaner ophthalmic solution 0.25% may eradicate Demodex mites and eliminate collarettes and eyelid redness 4

Treatment Algorithm

1. Begin with warm compresses and eyelid hygiene for 2-4 weeks 2
2. If inadequate response, add topical antibiotic ointment 1, 2
3. For severe or persistent cases, consider specialized treatments based on the type of blepharitis:
   • For posterior blepharitis/MGD: thermal pulsation treatment 5
   • For Demodex blepharitis: acaricide medication 3, 4
   • For associated dry eye: topical perfluorohexyloctane 1, 2

Common Pitfalls and Caveats

• Blepharitis is typically chronic and requires ongoing management rather than expecting complete cure 2, 6
• The multifactorial nature of blepharitis may lead to initial misdiagnoses and variability in treatment 6
• Long-term antibiotic use may lead to resistant organisms 2
• The frequency and duration of treatment should be guided by the severity of the blepharitis and response to treatment 1
• Blepharitis, if left untreated, has the potential to cause keratopathy, corneal neovascularization and ulceration, and permanent alterations in eyelid morphology 6