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

• Apply warm compresses to the eyelids for several minutes to soften adherent scales and warm meibomian secretions, using hot tap water on a clean washcloth, over-the-counter heat pack, or homemade bean/rice bag (ensuring the compress is not hot enough to burn the skin) 1, 2
• Perform eyelid cleansing through brief, gentle massage of the eyelids once or twice daily using diluted baby shampoo or commercially available eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip 1, 2
• For posterior blepharitis/MGD, perform vertical eyelid massage to express meibomian secretions 2
• Consider hypochlorous acid 0.01% eye cleaners which have strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• Use artificial tears to manage associated dry eye symptoms 2

Second-Line Treatment

• If inadequate response to eyelid hygiene after 2-4 weeks, add topical antibiotic ointment such as bacitracin or erythromycin applied to the eyelid margins one or more times daily for a few weeks 1, 2
• Use different antibiotics intermittently to prevent development of resistant organisms 1
• Consider topical perfluorohexyloctane for patients with associated dry eye disease, as it prevents tear evaporation and improves symptoms 1, 2

For Persistent or Severe Cases

• For Demodex blepharitis (characterized by collarettes at the base of eyelashes), consider specific anti-Demodex treatments 3
• In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered for recalcitrant cases 2, 4
• For severe or resistant cases, consider oral antibiotics, such as tetracyclines for adults or erythromycin for children and pregnant women 2

Special Considerations

• Tailor the therapeutic plan according to the patient's ability to perform eyelid hygiene safely, especially for those lacking manual dexterity 1
• Advise patients with advanced glaucoma or history of glaucoma filtering procedures to avoid aggressive pressure on the eyelids 1
• Counsel patients with neurotrophic corneas to avoid injury to corneal epithelium during eyelid cleansing 1
• Adjust frequency and duration of treatment based on the severity of blepharitis and response to treatment 1

Common Pitfalls and Caveats

• Blepharitis is typically chronic and complete cure is usually not possible; symptoms often recur when treatment is discontinued 1, 2
• Frequent manipulation of the eyelid may lead to mechanically induced irritation 1
• Long-term costs and potential adverse effects of commercial eyelid wipes should be considered 1
• Contrary to clinical dogma, younger individuals often report more, and more frequent, symptoms than older people 5
• The multifactorial nature of blepharitis (involving infection, inflammation, abnormal lid-margin secretions, and tear film abnormalities) necessitates addressing underlying causes rather than just symptoms 6, 7

Classification to Guide Treatment

• Anterior blepharitis affects the eyelid skin, base of eyelashes, and follicles; typically staphylococcal and/or seborrheic in nature 2, 6
• Posterior blepharitis (also known as Meibomian Gland Dysfunction or MGD) affects the meibomian glands; may be seborrheic, obstructive, or mixed 2, 6
• Treatment should address the specific type and underlying cause of blepharitis 4, 7