What is the treatment for Blepharitis?

Treatment of Blepharitis

First-Line Treatment: Eyelid Hygiene and Warm Compresses

Begin with daily warm compresses and eyelid hygiene for all blepharitis patients, maintaining this regimen long-term as blepharitis is a chronic condition without a definitive cure. 1, 2

Warm Compress Technique

• 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 2
• This softens crusts and warms meibomian secretions, particularly effective for posterior blepharitis/meibomian gland dysfunction (MGD) 1, 2
• Caution: Avoid compresses hot enough to burn the skin 1, 2
• Patients with advanced glaucoma should avoid aggressive lid pressure during massage as this may increase intraocular pressure 2

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 2
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• For MGD, perform vertical eyelid massage to express meibomian gland secretions 1, 2
• Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing 2

Adjunctive Measures

• Use artificial tears, especially those containing oil or lipid products, to manage associated dry eye symptoms 1

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Second-Line Treatment: Topical Antibiotics

If eyelid hygiene provides inadequate relief after 2-4 weeks, add topical antibiotics to the eyelid margins. 1, 2

Antibiotic Options

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks 1, 2
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 2, 3
• Topical tobramycin/dexamethasone suspension may reduce symptoms 2

Important Considerations

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1, 2
• Long-term antibiotic use risks creating resistant organisms 1, 2
• Adjust frequency and duration based on severity and treatment response 2
• Ofloxacin is not first-line and should be reserved for confirmed bacterial infection or when preparing for intraocular surgery 1

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Third-Line Treatment: Oral Antibiotics

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 2

Oral Antibiotic Regimens

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1, 2
• For women of childbearing age and children under 8 years: oral erythromycin or azithromycin 2
• Azithromycin pulse regimen: 1 g per week for 3 weeks or 500 mg daily for 3 days in three cycles with 7-day intervals 1, 2
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 2

Azithromycin Safety Warning

• Azithromycin may cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 1

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Specialized Treatments for Refractory Cases

Corticosteroids

• Short course of topical corticosteroids 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

Demodex-Specific Treatment

• Tea tree oil at 50% concentration for patients not improving with previous treatments 1, 2
• Metronidazole and ivermectin are alternative antiparasitic options 2

Additional Options

• Cyclosporine topical may be useful for posterior blepharitis and coexisting aqueous tear deficiency 1
• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms 1, 2
• In-office procedures (vectored thermal pulsation, microblepharoexfoliation) for recalcitrant cases 1, 2
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 1, 2

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Preoperative Management

Patients with moderate to severe blepharitis should be treated with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk. 2

• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection 2

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Critical Patient Education

• Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued 1, 2
• Long-term daily eyelid hygiene is essential for symptom control 1, 2
• Treatment requires persistence and often a trial-and-error approach 2
• Successful management depends on long-term treatment regimen compliance 1