Treatment of Blepharitis
Begin with daily warm compresses for 5-10 minutes 3-4 times daily plus eyelid cleansing with diluted baby shampoo or commercial eyelid cleaners once or twice daily, and add topical antibiotic ointment (bacitracin or erythromycin) only if inadequate response after 2-4 weeks. 1
Understanding the Condition
Blepharitis divides into two anatomic types that guide treatment selection:
- Anterior blepharitis affects the eyelid skin, base of eyelashes, and follicles 1
- Posterior blepharitis (Meibomian Gland Dysfunction/MGD) affects the meibomian glands 1
- This is a chronic condition requiring ongoing management rather than expecting complete cure 1
First-Line Treatment (Start Here for All Patients)
Warm Compresses
- Apply warm compresses for 5-10 minutes, 3-4 times daily to soften crusts and warm meibomian secretions 1
- Caution: Ensure compresses are not too hot to prevent skin burns 1
Eyelid Hygiene
- Clean eyelid margins once or twice daily using diluted baby shampoo or commercially available eyelid cleaners 1
- For posterior blepharitis/MGD, add vertical eyelid massage to help express meibomian secretions 1
- Hypochlorous acid 0.01% eye cleaners have strong antimicrobial effects for both anterior and posterior blepharitis 1
Artificial Tears
- Use artificial tears, especially those containing oil or lipid products, to manage associated dry eye symptoms 1
Duration
- Continue this regimen for 2-4 weeks before escalating treatment 1
Second-Line Treatment (If Inadequate Response After 2-4 Weeks)
Topical Antibiotics
- Add bacitracin or erythromycin ointment to the eyelid margins one or more times daily for a few weeks 1
- Azithromycin topical has shown efficacy in reducing signs and symptoms 1
- Use antibiotics intermittently with different medications to prevent development of resistant organisms 1
- Important: Long-term antibiotic use may lead to resistant organisms 1
Third-Line Treatment (For Severe or Resistant Cases)
Oral Antibiotics
- Doxycycline is a standard regimen for severe cases 1
- Alternative: Azithromycin oral pulse regimen of 1 g per week for 3 weeks 1
- For children under 8 years or pregnant women, use erythromycin instead of tetracyclines 1
- Caution: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1
Topical Corticosteroids
- Consider a short course for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1
- Loteprednol etabonate and fluorometholone phosphate are safer options due to their site-specific action and limited ocular penetration 1
Additional Options
- Cyclosporine topical may be useful for posterior blepharitis and coexisting aqueous tear deficiency 1
- Topical perfluorohexyloctane can prevent tear evaporation and improve symptoms in patients with associated dry eye disease 1
Advanced Treatment (For Recalcitrant Cases)
- In-office procedural treatments such as vectored thermal pulsation or microblepharoexfoliation may be considered 1
- Tea tree oil at 50% concentration can be considered for treatment of Demodex in patients who do not improve with previous treatments 1
Adjunctive Therapies
- Omega-3 fatty acid supplements have mixed evidence, with some studies showing improvement in tear break-up time, dry eye symptoms, and meibum score 1
Special Considerations
Pre-Surgical Preparation
- Consider antibiotics like ofloxacin when preparing for intraocular surgery to reduce the risk of endophthalmitis 1
- Note: Ofloxacin is not a first-line treatment for routine blepharitis 1
High-Risk Populations
- Avoid aggressive eyelid manipulation in patients with advanced glaucoma, as it may increase eye pressure 1
- Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1