What is the treatment for blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene as first-line therapy for all patients with blepharitis, escalating to topical antibiotics only if symptoms persist after 2-4 weeks of consistent eyelid care. 1, 2, 3

Critical Patient Counseling

• Patients must understand that blepharitis is a chronic, incurable condition requiring lifelong daily management—symptoms will recur when treatment stops. 1, 2, 3
• Complete cure is not possible; the goal is symptom control through persistent treatment. 1, 2

First-Line Treatment: Eyelid Hygiene Regimen

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily using hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags. 1, 3
• Warn patients explicitly to avoid compresses hot enough to burn the skin. 1, 3
• Warm compresses are particularly effective for posterior blepharitis/meibomian gland dysfunction (MGD) as they soften meibomian secretions. 1, 2, 3

Eyelid Cleansing

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a pad, cotton ball, cotton swab, or clean fingertip. 1, 3
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis. 1, 2, 3
• For MGD, perform vertical eyelid massage to express meibomian gland secretions. 1, 2, 3
• Rubbing eyelid margins side-to-side removes crusting from eyelashes. 1

Adjunctive Measures

• Artificial tears help manage associated dry eye symptoms. 2
• Maintain this regimen daily or several times weekly for long-term symptom control. 1, 3

Second-Line Treatment: Topical Antibiotics

Add topical antibiotics only if eyelid hygiene provides inadequate relief after 2-4 weeks. 2, 3

• Apply bacitracin or erythromycin ointment to eyelid margins one or more times daily or at bedtime for several weeks. 2, 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 2, 3
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms—long-term continuous antibiotic use creates resistance. 1, 2, 3
• Adjust frequency and duration based on severity and treatment response. 3

Third-Line Treatment: Oral Antibiotics

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 3

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement. 2, 3
• Alternative regimens for women of childbearing age and children under 8 years: oral erythromycin or azithromycin. 2, 3
• Azithromycin pulse regimen: 1 g per week for 3 weeks or 500 mg daily for 3 days in three cycles with 7-day intervals. 2, 3
• Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk. 2
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects. 3

Anti-Inflammatory Therapy

• Use a short course of topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules. 2
• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration. 2
• Topical cyclosporine may be useful in posterior blepharitis and can manage coexisting aqueous tear deficiency. 2

Specialized Treatments for Refractory Cases

Demodex Blepharitis

• Tea tree oil at 50% concentration for patients not improving with previous treatments. 2, 3
• Alternative antiparasitic options: metronidazole or ivermectin. 1, 3

Advanced Therapies

• Topical perfluorohexyloctane prevents tear evaporation and improves dry eye symptoms. 2, 3
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation) for recalcitrant cases. 1, 2, 3
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score. 2, 3

Critical Safety Considerations

High-Risk Populations

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure. 1, 3
• Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during eyelid cleansing. 1, 3
• Patients lacking manual dexterity or judgment should not perform eyelid massage due to injury risk. 1

Preoperative Management

• Patients with moderate to severe blepharitis require treatment with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk. 1, 3
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection. 1, 3

Treatment Algorithm Summary

1. Start: Daily warm compresses + eyelid hygiene (hypochlorous acid 0.01% preferred) + artificial tears 1, 2, 3
2. After 2-4 weeks if inadequate response: Add topical bacitracin or erythromycin ointment 2, 3
3. If still inadequate: Escalate to oral doxycycline or azithromycin 2, 3
4. For inflammation: Add short course topical corticosteroid (loteprednol or fluorometholone preferred) 2
5. For Demodex: Add tea tree oil 50%, metronidazole, or ivermectin 1, 2, 3
6. For refractory cases: Consider in-office procedures or topical perfluorohexyloctane 1, 2, 3