What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene as first-line therapy for all blepharitis patients, escalating to topical antibiotics only if symptoms persist after 2-4 weeks or when bacterial infection is evident. 1, 2

Understanding the Chronic Nature

• Patients must understand that blepharitis is typically chronic and cure is usually not possible, but continual daily treatment can significantly improve symptoms and quality of life. 1, 2
• Symptoms often recur when treatment is discontinued, requiring long-term management commitment. 1, 2

First-Line Treatment: Eyelid Hygiene Regimen

Warm Compresses:

• Apply warm compresses to eyelids for several minutes to soften adherent crusts and warm meibomian secretions. 1, 2
• Use hot tap water on clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags. 1
• Critical caveat: Instruct patients to avoid compresses so hot they burn the skin. 1, 2
• Perform once or twice daily at a time convenient for the patient. 1

Eyelid Cleansing:

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a pad, cotton ball, cotton swab, or clean fingertip. 1, 2
• Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis. 1, 2
• For posterior blepharitis/MGD, perform vertical eyelid massage to express meibomian glands, but with care to avoid mechanically induced irritation. 1, 2
• Important warning: Patients with advanced glaucoma should not place aggressive pressure on lids as it may increase intraocular pressure. 1
• Safety consideration: Patients lacking manual dexterity or those with neurotrophic corneas require proper counseling to avoid corneal epithelial injury. 1

Artificial Tears:

• Add artificial tears to manage associated dry eye symptoms. 1, 2

Second-Line Treatment: Topical Antibiotics

When to Escalate:

• Add topical antibiotics if inadequate response to eyelid hygiene after 2-4 weeks, or when signs of bacterial infection are present. 1, 2
• Consider antibiotics when preparing for intraocular surgery to reduce endophthalmitis risk (coagulase-negative Staphylococcus, S. aureus, and Streptococcus are common causative organisms). 1, 2

Topical Antibiotic Options:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for a few weeks. 1, 2
• Per FDA labeling, bacitracin ointment should be applied directly into the conjunctival sac 1-3 times daily; for blepharitis specifically, remove all scales and crusts first, then spread uniformly over lid margins. 3
• Azithromycin in sustained release system has shown efficacy in reducing signs and symptoms. 1, 2
• Topical tobramycin/dexamethasone suspension may reduce signs and symptoms (off-label use). 1

Critical Antibiotic Considerations:

• Use topical antibiotics intermittently with different medications and mechanisms of action to prevent development of resistant organisms. 1, 2
• Long-term antibiotic treatment may result in resistant organisms. 1, 2
• Frequency and duration should be guided by severity and response to treatment. 1, 2

Third-Line Treatment: Systemic Antibiotics for Refractory MGD

When to Use Oral Antibiotics:

• For patients with MGD whose chronic symptoms are not adequately controlled by eyelid cleansing or meibomian gland expression. 1, 2

Oral Antibiotic Options:

For Adults:

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement. 1, 2
• Tetracyclines decrease lipase production in S. epidermidis and S. aureus and have anti-inflammatory activity. 1
• Sustained-release doxycycline preparations can reduce side effects. 1

For Women of Childbearing Age and Children:

• Oral erythromycin or azithromycin as alternatives. 1, 2
• Azithromycin 500 mg per day for 3 days in three cycles with 7-day intervals, or 1 g per week for 3 weeks. 1, 2
• Erythromycin is appropriate for childhood blepharokeratitis when tetracyclines are contraindicated. 4

Tetracycline Contraindications and Side Effects:

• Absolutely contraindicated: Pregnancy, nursing women, children under 8 years (causes tooth staining). 1
• Side effects include photosensitization, gastrointestinal upset, vaginitis, rarely azotemia, and pseudotumor cerebri. 1
• May decrease effectiveness of oral contraceptives and potentiate warfarin effect. 1
• Minocycline can stain skin, nails, sclera, teeth, conjunctiva, tongue, and bone. 1

Azithromycin Warnings:

• May cause cardiac rhythm abnormalities, especially in patients with high baseline cardiovascular risk. 2

Additional Treatment Options

Anti-inflammatory Agents:

• Short course of topical corticosteroids for marked eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules. 2
• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration. 2
• Topical cyclosporine may be useful in some patients with posterior blepharitis and coexisting aqueous tear deficiency. 2

Newer Topical Agents:

• Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease. 1, 2

Antiparasitic Medications:

• Tea tree oil at 50% concentration for Demodex in patients not improving with previous treatments. 2
• Metronidazole, ivermectin, or lotilaner for parasitic causes. 1

In-Office Procedures:

• Vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases. 1, 2

Treatment Algorithm Summary

1. Weeks 0-4: Daily warm compresses + eyelid hygiene + artificial tears 1, 2
2. If inadequate response at 2-4 weeks: Add topical antibiotic ointment (bacitracin or erythromycin) 1, 2
3. If still inadequate or severe MGD: Add oral tetracyclines (adults) or erythromycin/azithromycin (children/pregnant women) 1, 2
4. For marked inflammation: Consider short course topical corticosteroids 2
5. For refractory cases: Consider in-office procedures or antiparasitic therapy 1, 2

Long-Term Management

• Daily eyelid hygiene is essential for long-term control and must be continued indefinitely. 2
• Treatments can be intermittently discontinued and reinstated based on severity and medication tolerance. 1
• Regular monitoring is necessary, especially for patients on systemic antibiotics. 1