What is the appropriate management for an adolescent with persistent crusting on their eyes for 6 months?

Management of Persistent Eye Crusting in an Adolescent

This adolescent with 6 months of eye crusting most likely has chronic blepharitis and should be treated with a regimen of warm compresses, eyelid hygiene with massage, and topical antibiotic ointment (bacitracin or erythromycin) applied to the eyelid margins. 1

Initial Treatment Approach

First-Line Therapy: Eyelid Hygiene and Warm Compresses

• Apply warm compresses to the eyelids for several minutes using hot tap water on a clean washcloth, an over-the-counter heat pack, or a homemade bean/rice bag heated in the microwave to soften adherent crusts and scales 1
• Instruct the patient to avoid compresses that are so hot they burn the skin 1
• Perform eyelid cleansing after warm compresses by gently rubbing the base of the eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1
• Rub the eyelid margins from side to side to remove crusting from the eyelashes 1
• Eye cleaners with hypochlorous acid at 0.01% have strong antimicrobial effects and can be used for anterior blepharitis 1

Topical Antibiotic Therapy

• Apply topical antibiotic ointment such as bacitracin or erythromycin to the eyelid margins one or more times daily 1
• For bacitracin ointment, all scales and crusts should be carefully removed first, then the ointment spread uniformly over the lid margins 2
• Bacitracin ointment should be applied directly into the conjunctival sac 1 to 3 times daily 2
• Erythromycin ophthalmic ointment approximately 1 cm in length can be applied up to six times daily depending on severity 3
• Topical antibiotics have been shown to provide symptomatic relief and decrease bacteria from the eyelid margin in cases of anterior blepharitis 1

Treatment Schedule and Duration

• Once- or twice-daily compresses and massage at a time most convenient for the patient is generally adequate 1
• A schedule of regularly performed eyelid cleansing, daily or several times weekly, often blunts the symptoms of chronic blepharitis 1
• Patients should be advised that warm compress and eyelid cleansing treatment may be required long term, because symptoms often recur when treatment is discontinued 1

Critical Patient Counseling

• The patient must understand that a cure is usually not possible 1
• The optimal treatment regimen often requires persistence and a trial-and-error approach 1
• Patients who lack manual dexterity or necessary skill should be counseled carefully, as cleaning the eyelid using these devices and/or digital massage can potentially be dangerous 1
• Frequent manipulation of the eyelid may lead to mechanically induced irritation, so caution is warranted 1

When to Consider Additional Interventions

• If symptoms persist despite eyelid hygiene and topical antibiotics, consider adding topical anti-inflammatory agents such as corticosteroids or cyclosporine 1
• Evidence on the effectiveness of topical corticosteroids or oral antibiotics for blepharitis has been shown to be inconclusive 1
• Long-term antibiotic treatment may result in the development of resistant organisms, so this should be considered when planning extended therapy 1

Important Pitfalls to Avoid

• Do not recommend aggressive pressure on the lids in patients with advanced glaucoma or history of glaucoma filtering procedures, as this may subsequently increase eye pressure 1
• Proper counseling of patients with neurotrophic corneas is important to avoid injury to corneal epithelium during eyelid cleansing 1
• Patients should be instructed to take appropriate measures to avoid gross contamination of the ointment when applying directly to the eye 2