What is the treatment for blepharitis?

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
• Both types are chronic conditions 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

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 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
• Frequency and duration should be guided by severity and response to treatment 1

When to Consider Antibiotics Earlier

• Consider antibiotics when first-line measures provide inadequate relief 1
• Use when there are signs of bacterial infection 1
• Consider ofloxacin when preparing for intraocular surgery to reduce endophthalmitis risk 1

Third-Line Treatment (For Severe or Resistant Cases)

Oral Antibiotics

• Doxycycline is the 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
• Important: 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
• Use with caution and monitor intraocular pressure closely, especially in patients with advanced glaucoma 1

Additional Adjunctive Therapies

• 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 1
• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time and dry eye symptoms 1
• Tea tree oil at 50% concentration can be considered for Demodex in patients who do not improve with previous treatments 1

In-Office Procedural Treatments

For recalcitrant cases, consider:

• Vectored thermal pulsation 1
• Microblepharoexfoliation 1

Critical Patient Education Points

• Blepharitis is typically chronic and cannot be permanently cured; successful management depends on long-term treatment regimen compliance 1
• Daily eyelid hygiene is essential for long-term control 1
• Symptoms often recur when treatment is discontinued 1
• Long-term antibiotic use may lead to resistant organisms 1

Special Population Considerations

• Pregnant women and children under 8: Avoid tetracyclines; use erythromycin if oral antibiotics needed 1
• Advanced glaucoma patients: Avoid aggressive eyelid manipulation as it may increase eye pressure; use steroid-containing drops with caution 1
• Neurotrophic corneas: Counsel patients to avoid injury to corneal epithelium during eyelid cleaning 1