What treatment to give for blepharitis?

Treatment of Blepharitis

Start all patients with warm compresses for several minutes and eyelid cleansing daily, which forms the foundation of blepharitis management regardless of type. 1, 2

Understanding the Condition First

Blepharitis is a chronic condition where cure is usually not possible—patients must understand this requires ongoing management rather than expecting complete resolution. 1, 2 The disease has two main forms:

• Anterior blepharitis affects the eyelid skin, base of eyelashes, and follicles 2
• Posterior blepharitis (Meibomian Gland Dysfunction/MGD) affects the meibomian glands 2

First-Line Treatment Algorithm

Step 1: Warm Compresses (Essential for All Types)

• Apply warm compresses to eyelids for 5-10 minutes once or twice daily to soften adherent crusts and warm meibomian secretions 1, 3
• Use hot tap water on clean washcloth, over-the-counter heat pack, or microwaveable bean/rice bag 1
• Critical warning: Instruct patients to avoid compresses hot enough to burn the skin 1, 3
• Patients with advanced glaucoma should avoid aggressive lid pressure during treatment to prevent increased intraocular pressure 3

Step 2: Eyelid Cleansing (Especially Important for Anterior Blepharitis)

• Clean eyelid margins using diluted baby shampoo or commercially available eyelid cleaner on cotton pad, ball, swab, or clean fingertip 1, 3
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 2, 3
• For posterior blepharitis/MGD, perform vertical eyelid massage after warm compresses to express meibomian secretions 1, 2
• Rub eyelid margins side-to-side to remove crusting from eyelashes 1

Step 3: Artificial Tears

• Add artificial tears, especially oil or lipid-containing products, to manage associated dry eye symptoms 2

Second-Line Treatment: When to Add Antibiotics

Add topical antibiotics after 2-4 weeks if eyelid hygiene provides inadequate relief or when signs of bacterial infection are present. 2

Topical Antibiotic Options

• Bacitracin ointment: Apply directly to lid margins 1-3 times daily after removing all scales and crusts, spreading uniformly over lid margins 4
• Erythromycin ointment: Alternative first-line antibiotic option 2
• Apply to eyelid margins one or more times daily for a few weeks 2
• Important caveat: Use antibiotics intermittently with different medications to prevent resistant organisms—long-term continuous antibiotic treatment may result in resistance 1, 2

When Antibiotics Are Specifically Indicated

• Consider antibiotics like ofloxacin when preparing for intraocular surgery to reduce endophthalmitis risk (causative organisms include coagulase-negative Staphylococcus 68.4%, S. aureus 6.8%, Streptococcus 8.2%) 1, 2
• However, no evidence proves preoperative treatment prevents endophthalmitis 1

Third-Line Treatment: Persistent or Severe Cases

Systemic Antibiotics

• Doxycycline: Standard regimen for severe cases 2
• Azithromycin: 1 g per week for 3 weeks (oral pulse regimen) 2
• Warning: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 2
• Contraindications: Tetracyclines contraindicated in pregnancy, nursing women, and children under 8 years 3
• Alternative for children/pregnancy: Erythromycin 2, 3

Anti-Inflammatory Agents

• Short-course topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2, 3
• Safer corticosteroid options: Loteprednol etabonate and fluorometholone phosphate due to site-specific action and limited ocular penetration 2
• Topical cyclosporine may help in posterior blepharitis with coexisting aqueous tear deficiency 2

Additional Options

• Tacrolimus 0.1% ointment applied once daily to external eyelids and lid margins for 2-4 weeks for atopic eyelid dermatitis 3
• Omega-3 fatty acid supplements have mixed evidence but may improve tear break-up time and meibum score 2
• Tea tree oil 50% for Demodex in patients not improving with previous treatments 2

Common Pitfalls to Avoid

• Don't expect cure: Symptoms often recur when treatment is discontinued—emphasize long-term daily eyelid hygiene for control 2, 3
• Assess patient capability: Consider manual dexterity and judgment before recommending digital massage, as improper technique can be dangerous 1
• Special populations: Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during cleansing 3
• Avoid prolonged continuous antibiotics: This creates resistant organisms—use intermittently 1, 2