What is the treatment for blepharoconjunctivitis?

Treatment of Blepharoconjunctivitis

Begin with daily eyelid hygiene (warm compresses and lid cleansing) combined with topical antibiotic ointment (bacitracin or erythromycin) applied to the eyelid margins, and escalate to oral antibiotics (erythromycin in children, doxycycline in adults) for posterior disease or cases unresponsive to initial therapy. 1

Initial Treatment Approach

Eyelid Hygiene (Essential for All Cases)

• Apply warm compresses for several minutes to soften adherent scales and warm meibomian gland secretions 1
• Perform gentle eyelid cleansing using diluted baby shampoo or commercially available eyelid cleaners on a cotton swab, pad, or clean fingertip to remove crusting from the eyelash base 1
• Add hypochlorous acid 0.01% eye cleaners which provide antimicrobial effects for both anterior and posterior blepharitis 2, 3
• Perform meibomian gland expression through digital massage, particularly helpful for posterior blepharitis/MGD, but avoid aggressive pressure in patients with advanced glaucoma as this may increase intraocular pressure 1, 4
• Schedule this regimen once or twice daily at a convenient time; patients must understand this is typically required long-term as symptoms recur when discontinued 1

Topical Antibiotic Therapy (For Anterior Blepharitis)

• Apply bacitracin or erythromycin ointment to the eyelid margins 1-3 times daily or at bedtime for several weeks after carefully removing all scales and crusts 1, 5
• These topical antibiotics provide symptomatic relief and effectively decrease bacterial load from the eyelid margin 1, 6
• Rotate different antibiotics intermittently using medications with different mechanisms of action to prevent development of resistant organisms 1, 3
• The frequency and duration should be guided by severity and response to treatment 1

Escalation for Posterior Blepharitis/MGD

When eyelid hygiene and topical therapy fail to adequately control chronic symptoms and signs:

Oral Antibiotic Options for Adults

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1
• These tetracyclines decrease lipase production in S. epidermidis and S. aureus and provide anti-inflammatory activity 1
• Oral azithromycin 500 mg daily for 3 days in three cycles with 7-day intervals between cycles has demonstrated good clinical improvement 3
• The FDA warns that oral azithromycin may cause cardiac electrical abnormalities with potential for serious heart rhythm irregularities, particularly in high cardiovascular risk patients 3, 4

Oral Antibiotic Options for Children and Women of Childbearing Age

• Oral erythromycin is the preferred systemic antibiotic when tetracyclines are contraindicated 1, 2
• Pediatric dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 2, 4
• Tetracyclines must not be used in children under 8 years of age due to risk of permanent dental staining 1, 2
• Oral erythromycin combined with topical steroids successfully treats childhood blepharokeratoconjunctivitis, with symptom relief within 2-3 weeks and progressive improvement by 2 months 7, 8

Topical Azithromycin for Moderate to Severe Cases

• Apply azithromycin 1% ophthalmic solution twice daily for 2 days, then once daily for 12 days, combined with warm compresses 3
• This provides both antimicrobial and anti-inflammatory effects, particularly effective for posterior blepharitis and MGD 3, 4

Anti-Inflammatory Therapy

• Short-term topical corticosteroids (1-2 weeks) may be added for significant inflammation or corneal involvement 2, 3
• Use the minimal effective dose to minimize steroid-related complications 3
• Topical cyclosporine A 1% can be useful as an adjunct to lid hygiene and lubricants, leading to improvement of dry eye symptoms and reduced inflammation 9

Special Considerations for Children

• Chronic blepharokeratoconjunctivitis in children is often unrecognized and should be suspected with recurrent conjunctivitis, keratitis, neovascularization, eyelid inflammation, hordeolum, and chalazia 1
• The presentation can be asymmetric and is often confused with herpetic disease 1
• A Cochrane systematic review reports uncertainty regarding effectiveness of both topical and systemic treatments in children due to lack of high-quality evidence, but clinical experience supports the erythromycin-based regimen 2, 6

Critical Pitfalls to Avoid

• Patients must understand that cure is usually not possible and treatment is aimed at controlling symptoms; blepharitis reactivates in all patients during follow-up requiring repeat therapy 1, 7
• Avoid aggressive lid pressure in patients with advanced glaucoma or history of glaucoma filtering procedures 1
• Ensure patients have adequate manual dexterity and judgment to perform lid hygiene safely; tailor the therapeutic plan accordingly 1
• Counsel patients with neurotrophic corneas carefully to avoid corneal epithelial injury during lid cleansing 1
• Long-term antibiotic treatment may result in development of resistant organisms 1
• Tetracyclines cause photosensitization, gastrointestinal upset, and may alter effectiveness of oral contraceptives and potentiate warfarin effect 1

Preoperative Management

• Address moderate to severe blepharitis with topical antibiotics and eyelid hygiene prior to intraocular surgery to control symptoms and signs, as the usual ocular surface pathogens associated with blepharitis (coagulase-negative Staphylococcus, S. aureus, Streptococcus species) are the causative organisms in postoperative endophthalmitis 1
• However, there is no evidence proving such treatment will prevent endophthalmitis 1