What is the recommended treatment approach for a patient with blepharitis?

Treatment of Blepharitis

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

Understanding the Chronic Nature

• Blepharitis is a chronic, incurable condition where symptoms recur when treatment is discontinued—patients must understand that long-term daily eyelid hygiene is essential for symptom control, not cure. 1, 2
• The condition can be classified as anterior blepharitis (affecting eyelid skin, lash base, and follicles) or posterior blepharitis/meibomian gland dysfunction (MGD) affecting the meibomian glands. 2

First-Line Treatment (Weeks 1-4)

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
• Ensure compresses are not hot enough to burn the skin. 1
• Warm compresses are especially effective for posterior blepharitis/MGD as they soften crusts and warm meibomian secretions. 1, 2

Eyelid Hygiene

• 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
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis. 1, 2
• For MGD specifically, perform vertical eyelid massage to express meibomian gland secretions. 1, 2
• Remove all scales and crusts carefully before applying any treatments. 3

Adjunctive Measures

• Use preservative-free artificial tears for patients with poor ocular surface condition or those using drops more than 4 times daily. 1
• Consider lipid-containing artificial tear supplements if meibomian gland dysfunction is present. 1

Second-Line Treatment (After 2-4 Weeks Without Adequate Relief)

Topical Antibiotics

• Add bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks. 1, 2, 3
• The FDA-approved dosing for bacitracin is application directly to the conjunctival sac 1 to 3 times daily, with ointment spread uniformly over lid margins after removing all scales and crusts. 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 1, 2
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms—long-term antibiotic use risks creating resistant bacteria. 1, 2
• Adjust frequency and duration based on severity and treatment response. 1

Topical Corticosteroids (When Inflammation is Prominent)

• 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 their site-specific action and limited ocular penetration. 2
• For severe cases, stronger potency steroids such as betamethasone may be considered. 1
• Long-term low-dose topical steroids are reserved only for patients with autoimmune diseases or moderate to severe dry eye disease. 1

Third-Line Treatment (For MGD With Inadequate Response)

Oral Antibiotics

• Escalate to doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement. 1, 2
• Alternative oral antibiotic regimens include oral erythromycin or azithromycin for women of childbearing age and children under 8 years. 1, 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. 1
• Be aware that azithromycin may cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk. 2

Specialized Treatments for Specific Etiologies

Demodex Blepharitis

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

Advanced In-Office Procedures (For Recalcitrant Cases)

• Vectored thermal pulsation or microblepharoexfoliation can be used when conservative measures fail. 1, 2
• Physical heating and expression of the meibomian glands may be performed. 1
• Intense pulsed light therapy and/or thermo pulsation therapy are additional options. 1

Supplemental Therapies

• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms. 1, 2
• Cyclosporine topical may be useful in some patients with posterior blepharitis and can also help manage coexisting aqueous tear deficiency. 2
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score. 1, 2

Critical Pitfalls and Special Populations

Avoid These Common Errors

• Do not prescribe ofloxacin or other fluoroquinolones as first-line treatment—reserve these for cases with confirmed bacterial infection or when preparing for intraocular surgery. 2
• Patients should not independently purchase over-the-counter eye drops, as many contain preservatives or vasoconstricting agents. 1
• Caution against certain cosmetics that may exacerbate symptoms. 1

High-Risk Patients Requiring Special Precautions

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure. 1
• Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing. 1
• Preoperative patients with moderate to severe blepharitis should be treated with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk. 1
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection. 1

Environmental and Lifestyle Modifications

• Blink more frequently (>10 times/minute) when using computers or watching TV. 1
• Avoid wind exposure and dry environments; air-conditioned environments increase the risk of dry eye disease. 1
• Consider Mediterranean-diet-oriented dietary modifications. 1
• Use moisture chamber spectacles/goggles for severe cases. 1
• Apply overnight treatments such as ointment or moisture chamber devices. 1