What is the management approach for blepharitis?

Management of Blepharitis

Begin with daily warm compresses for several minutes followed by eyelid cleansing using diluted baby shampoo or hypochlorous acid 0.01% solution, performed once or twice daily as the foundation of treatment for all forms of blepharitis. 1, 2

Initial Conservative Management (First 2-4 Weeks)

Warm Compress Technique

• Apply warm compresses to eyelids for several minutes to soften adherent crusts and warm meibomian secretions 1
• Use hot tap water on a clean washcloth, over-the-counter heat pack, or microwaveable bean/rice bag 1
• Critical warning: Instruct patients to avoid compresses hot enough to burn the skin 1
• Patients with advanced glaucoma should avoid aggressive lid pressure as it may increase intraocular pressure 1

Eyelid Cleansing Protocol

• Hypochlorous acid 0.01% cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• Alternative: diluted baby shampoo or commercially available eyelid cleaners applied with a pad, cotton ball, or clean fingertip 1, 2
• Perform gentle massage of eyelids, rubbing margins side-to-side to remove crusting from eyelashes 1
• For posterior blepharitis/meibomian gland dysfunction: add vertical eyelid massage to express meibomian secretions 1, 2
• Caution patients with neurotrophic corneas to avoid corneal epithelial injury during cleansing 1

Adjunctive Measures

• Add artificial tears to manage associated dry eye symptoms 2
• Establish a schedule of daily or several-times-weekly eyelid cleansing for long-term symptom control 1

Second-Line Treatment: Topical Antibiotics

If inadequate response after 2-4 weeks of eyelid hygiene, add topical antibiotic ointment to the eyelid margins. 2

Antibiotic Selection

• Bacitracin or erythromycin ointment are first-line antibiotic choices 2
• Apply to eyelid margins one or more times daily or at bedtime for a few weeks 1
• Azithromycin has demonstrated efficacy in reducing signs and symptoms 2
• Rotate between different antibiotics with different mechanisms of action to prevent resistant organisms 1, 2
• Frequency and duration should be guided by severity and treatment response 1

Special Circumstances

• Consider antibiotics like ofloxacin when preparing for intraocular surgery to reduce endophthalmitis risk 2
• Ofloxacin is not first-line and should be reserved for confirmed bacterial infection or preoperative preparation 2

Advanced Treatment Options

For Persistent or Severe Cases

• Topical perfluorohexyloctane (FDA-approved 2023) prevents tear evaporation and improves symptoms and corneal staining after 8 weeks 1, 2
• Selenium sulfide breaks disulfide bonds to unblock meibomian gland orifices and decrease meibum viscosity 1
• Consider oral antibiotics: tetracyclines for adults or erythromycin for children and pregnant women 2
• In-office procedures: vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 2

Demodex-Specific Treatment

• Screen for collarettes at the base of eyelashes, which are pathognomonic for Demodex blepharitis 3, 4
• Demodex infestation causes more than two-thirds of all blepharitis cases in the United States 3
• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy for Demodex blepharitis, eradicating mites in 50-67% of patients 3, 4
• Successful Demodex treatment may reduce chronic healthcare resource utilization for dry eye and other ocular surface diseases 3

Critical Management Principles

Long-Term Expectations

• Blepharitis is typically chronic and requires ongoing management rather than expecting complete cure 2
• Symptoms often recur when treatment is discontinued, necessitating long-term warm compress and eyelid cleansing 1, 2
• Daily eyelid hygiene is essential for long-term control 2

Common Pitfalls to Avoid

• Frequent eyelid manipulation may cause mechanically induced irritation 1
• Long-term antibiotic use may lead to resistant organisms 2
• Lack of patient counseling about chronic nature leads to poor adherence and treatment failure 2
• Failure to screen for Demodex infestation misses an underlying treatable cause in the majority of cases 3