What is the best treatment approach for a patient with chronic blepharitis?

Treatment of Chronic Blepharitis

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

Understanding the Chronic Nature

• Blepharitis cannot be permanently cured and requires lifelong management—patients must understand that successful control depends entirely on their compliance with ongoing treatment. 1, 2
• Symptoms typically recur when treatment is discontinued, making daily maintenance essential rather than optional. 2, 3
• Distinguish between anterior blepharitis (affecting the lash line) and posterior blepharitis/meibomian gland dysfunction (MGD), as morning symptom worsening suggests blepharitis while late-day worsening suggests aqueous deficient dry eye. 1

First-Line Treatment: Eyelid Hygiene (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, 3
• Critical warning: Instruct patients to avoid compresses hot enough to burn the skin. 1, 3
• This softens adherent crusts and warms meibomian secretions, particularly effective for posterior blepharitis/MGD. 1, 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 specifically, perform vertical eyelid massage to express meibomian gland secretions. 2, 3
• Rubbing the eyelid margins side-to-side removes crusting from eyelashes. 1

Special Population Warnings:

• Patients with advanced glaucoma should avoid aggressive lid pressure during massage as this may increase intraocular pressure. 3
• Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during cleansing. 3

Second-Line Treatment: Topical Antibiotics (After 2-4 Weeks)

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

Preferred Topical Options:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks. 1, 2, 3
• Per FDA labeling, bacitracin ointment should be applied directly into the conjunctival sac 1-3 times daily, with all scales and crusts carefully removed before spreading uniformly over lid margins. 4
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 2, 3

Critical Antibiotic Considerations:

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms—this is a major pitfall of long-term management. 1, 2, 3
• Adjust frequency and duration based on severity and treatment response rather than using fixed protocols. 1, 3
• Long-term antibiotic use risks creating resistant organisms. 2, 3

Third-Line Treatment: Oral Antibiotics (For Severe/Resistant Cases)

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

Oral Antibiotic Regimens:

• 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. 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
• Important cardiac warning: Azithromycin may cause cardiac arrhythmias when used orally in patients with cardiovascular problems. 1, 2
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects. 3

Adjunctive Therapies

For Associated Dry Eye:

• Topical perfluorohexyloctane (FDA-approved 2023) prevents tear evaporation and improves symptoms and corneal staining after 8 weeks. 1, 2, 3
• Use preservative-free artificial tears for patients with poor ocular surface or those using drops more than 4 times daily. 3
• Consider lipid-containing supplements if meibomian gland dysfunction is present. 3

For Inflammation:

• 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
• Long-term low-dose topical steroids are reserved only for patients with autoimmune diseases or moderate to severe dry eye disease. 3

For Demodex Blepharitis:

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

In-Office Procedures for Recalcitrant Cases

• Physical heating and expression of meibomian glands, vectored thermal pulsation, or microblepharoexfoliation may be considered. 2, 3
• Important caveat: There is a lack of independent, randomized controlled studies demonstrating superiority of any one in-office treatment over another. 1

Red Flags Requiring Further Investigation

In patients with blepharitis who do not respond to therapy, consider carcinoma or immune-mediated diseases, particularly if associated with loss of eyelashes and/or conjunctival cicatricial changes—early diagnosis can prevent vision loss, disfigurement, and may be lifesaving. 1

Preoperative Considerations

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