Management of Blepharitis
Begin with daily warm compresses for several minutes followed by eyelid cleansing using diluted baby shampoo or hypochlorous acid 0.01% cleaners, performed once or twice daily as the foundation of treatment for all blepharitis cases. 1, 2
Initial Conservative Management (First 2-4 Weeks)
Warm Compress Therapy
- Apply warm compresses to eyelids for several minutes to soften crusts and warm meibomian secretions 1, 2
- Use hot tap water on clean washcloth, over-the-counter heat packs, or microwavable bean/rice bags 1
- Critical warning: Instruct patients to avoid compresses hot enough to burn the skin 1, 2
- Patients with advanced glaucoma should avoid aggressive lid pressure as it may increase intraocular pressure 1
Eyelid Cleansing Techniques
- 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 pad, cotton ball, or clean fingertip 1, 2
- For posterior blepharitis/MGD: perform vertical eyelid massage to express meibomian secretions 1, 2
- Rub eyelid margins side-to-side to remove crusting from eyelashes 1
- Caution patients with neurotrophic corneas to avoid corneal epithelial injury during cleansing 1
Adjunctive Measures
- Prescribe artificial tears, particularly oil or lipid-containing products, for associated dry eye symptoms 2
- Schedule: once or twice daily at patient's convenience, continued long-term 1, 2
Second-Line Treatment (If Inadequate Response After 2-4 Weeks)
Topical Antibiotic Therapy
- Add bacitracin or erythromycin ointment to eyelid margins once or more times daily or at bedtime for several weeks 1, 2
- Rotate between different antibiotic classes intermittently to prevent resistant organism development 1, 2
- Azithromycin topical has demonstrated efficacy in reducing blepharitis signs and symptoms 2
- Reserve ofloxacin for confirmed bacterial infection or pre-operative preparation before intraocular surgery to reduce endophthalmitis risk 2
Anti-Inflammatory Options
- Short course of topical corticosteroids for significant eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2
- Prefer loteprednol etabonate or fluorometholone phosphate due to safer profiles with site-specific action and limited ocular penetration 2
- Topical cyclosporine may benefit posterior blepharitis patients with coexisting aqueous tear deficiency 2
Third-Line Treatment (Severe or Resistant Cases)
Systemic Antibiotics
- Doxycycline is the standard oral regimen for severe blepharitis 2
- Alternative: azithromycin 1 gram weekly for 3 weeks 2
- Warning: Azithromycin may cause cardiac rhythm abnormalities, especially in patients with baseline cardiovascular risk 2
- For children and pregnant women: oral erythromycin 2
Advanced Topical Therapies
- Topical perfluorohexyloctane (FDA-approved 2023) prevents tear evaporation and improves symptoms and corneal staining after 8 weeks 1, 2
- Selenium sulfide for MGD: breaks disulfide bonds to unblock meibomian gland orifices and decrease meibum viscosity 1
Specialized Treatments
- Tea tree oil 50% concentration for Demodex in treatment-refractory cases 2
- Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 2
- In-office procedures: vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 2
Critical Patient Education Points
- Blepharitis is typically chronic and cannot be permanently cured; symptoms recur when treatment is discontinued 1, 2
- Daily eyelid hygiene must continue long-term for symptom control 1, 2
- Treatment frequency and duration should be guided by severity and response 1, 2
- Patients lacking manual dexterity require modified treatment plans to avoid injury 1