What is the recommended treatment 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 conservative management. 1

First-Line Treatment: Eyelid Hygiene Regimen

This is the foundation of blepharitis management and must be maintained long-term, as this is a chronic condition without a definitive cure. 1

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily to soften crusts and warm meibomian secretions 1
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags 1
• Avoid compresses hot enough to burn the skin 1
• This is especially effective for posterior blepharitis/meibomian gland dysfunction (MGD) 1

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
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1
• For MGD, perform vertical eyelid massage to express meibomian gland secretions 1
• Maintain this regimen daily or several times weekly to control chronic symptoms 1

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 supplements if meibomian gland dysfunction is present 1

Second-Line Treatment: Topical Antibiotics

Add topical antibiotics only if eyelid hygiene provides inadequate relief after 2-4 weeks. 1

• Apply bacitracin or erythromycin ointment 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 1, 2
• Topical tobramycin/dexamethasone suspension may reduce symptoms 1
• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1
• Adjust frequency and duration based on severity and treatment response 1

Important Caveat

Long-term antibiotic use risks creating resistant organisms, so use judiciously and intermittently. 1, 2

Third-Line Treatment: Oral Antibiotics

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 1

Adult Regimens

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 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
• These provide both antimicrobial and anti-inflammatory effects 1

Special Populations

• Use oral erythromycin or azithromycin for women of childbearing age and children under 8 years 1, 2
• Note: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 2

Specialized Treatments for Refractory Cases

Demodex Blepharitis

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

Advanced Therapies

• 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

Corticosteroids

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

Critical Patient Education

Patients must understand that 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 1
• Successful management depends on long-term treatment regimen compliance 2

Special Population Considerations

High-Risk Patients

• 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 Management

• Patients with moderate to severe blepharitis should be treated with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 1, 2
• 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 1
• Caution against certain cosmetics 1
• Consider Mediterranean-diet-oriented dietary modifications 1
• Do not independently purchase over-the-counter eye drops, as many contain preservatives or vasoconstricting agents 1