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

Chronic Blepharitis Treatment

Begin with daily warm compresses and eyelid hygiene as foundational therapy, escalating to topical antibiotics (bacitracin or erythromycin ointment) if symptoms persist after 2-4 weeks, and reserve oral tetracyclines for severe or refractory cases. 1, 2, 3

First-Line Treatment: Eyelid Hygiene Regimen

The cornerstone of chronic blepharitis management is a consistent daily eyelid hygiene routine that must be maintained long-term, as this is a chronic condition without definitive cure. 1, 2, 3

Warm Compresses

• Apply warm compresses to eyelids for several minutes once or twice daily to soften crusts and warm meibomian secretions. 2, 3
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags. 3
• Caution patients to avoid compresses hot enough to burn the skin. 2, 3
• Warm compresses are particularly effective for posterior blepharitis/meibomian gland dysfunction (MGD). 2, 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 once or twice daily. 2, 3
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis. 2, 3

Meibomian Gland Expression

• For MGD, perform vertical eyelid massage to express meibomian gland secretions after warm compresses. 2, 3
• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure. 3

Adjunctive Measures

• Artificial tears, especially lipid-containing formulations, help manage associated dry eye symptoms. 1, 2
• Use preservative-free artificial tears for patients with poor ocular surface condition or those using drops more than 4 times daily. 3

Second-Line Treatment: Topical Antibiotics

If eyelid hygiene provides inadequate relief after 2-4 weeks, add topical antibiotics. 2, 3

Antibiotic Options

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks is the preferred first-line antibiotic therapy. 2, 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 2, 3
• Topical tobramycin/dexamethasone suspension may reduce symptoms in uncontrolled studies. 3

Important Antibiotic Considerations

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms. 2, 3
• Long-term antibiotic use risks creating resistant organisms. 2, 3
• Adjust frequency and duration based on severity and treatment response. 3

Third-Line Treatment: Oral Antibiotics

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 2, 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. 2, 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
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects. 3

Azithromycin Warning

• Azithromycin may cause abnormalities in heart electrical activity with potential for serious cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk. 2

Adjunctive Anti-Inflammatory Therapy

Topical Corticosteroids

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

Other Anti-Inflammatory Options

• Cyclosporine topical may be useful in some patients with posterior blepharitis and can also help manage coexisting aqueous tear deficiency. 2
• Topical perfluorohexyloctane can prevent tear evaporation and improve dry eye symptoms. 2, 3

Specialized Treatments for Demodex Blepharitis

• Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments for Demodex blepharitis. 2, 3
• Metronidazole and ivermectin are alternative antiparasitic options for Demodex blepharitis. 3
• Microscopic evaluation of epilated eyelashes for Demodex mites can be performed by placing explanted eyelashes on a glass slide with fluorescein and a cover slip. 4, 1

Advanced In-Office Procedures

For recalcitrant cases, consider: 2, 3

• Vectored thermal pulsation
• Microblepharoexfoliation
• Physical heating and expression of the meibomian glands
• Intense pulsed light therapy and/or thermo pulsation therapy

Supplemental Therapies

• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score. 2, 3
• Moisture chamber spectacles/goggles for severe cases. 3
• Overnight treatments such as ointment or moisture chamber devices. 3

Critical Pitfalls and Red Flags

Chronic Unresponsive Blepharitis

• Consider carcinoma in cases of chronic blepharitis unresponsive to therapy, especially with unilateral involvement. 4, 1
• Eyelid biopsy may be indicated for marked asymmetry, resistance to therapy, or unifocal recurrent chalazia. 4, 1
• Additional signs of concern include loss of normal eyelid margin and conjunctival anatomy, and focal lash loss (ciliary madarosis). 4
• Before obtaining a biopsy for suspected sebaceous carcinoma, consultation with a pathologist is recommended to discuss the potential need for frozen sections and mapping of the conjunctiva. 4

Cicatrizing Disease

• Perform a complete ocular surface exam on patients with chronic blepharitis unresponsive to standard medical treatment to look for signs of conjunctival cicatricial changes. 4
• If there are signs of cicatrizing disease such as forniceal foreshortening, suspect ocular mucous membrane pemphigoid (OMMP) and initiate proper workup including immunofluorescence studies. 4

Pediatric Considerations

• Pediatric blepharokeratoconjunctivitis is often unrecognized and can be more severe, potentially leading to amblyopia. 4, 1

Medication-Induced Blepharitis

• Isotretinoin and dupilumab can induce or worsen blepharitis. 1

Surgical Risk

• Blepharitis is a risk factor for endophthalmitis after intraocular surgery and intravitreal injection; address moderate to severe blepharitis with topical antibiotics and eyelid hygiene prior to intraocular procedures. 1, 3

Special Populations

• Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing. 3

Essential Patient Education

• Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued. 1, 2, 3
• Long-term daily eyelid hygiene is essential for symptom control. 2, 3
• Treatment requires persistence and often a trial-and-error approach. 3
• Maintain this regimen daily or several times weekly to help control chronic symptoms. 3

Environmental and Lifestyle Modifications

• Blink more frequently (>10 times/minute) when using computers or watching TV. 3
• Avoid wind exposure and dry environments. 3
• Air-conditioned environments increase the risk of dry eye disease. 3
• Caution against certain cosmetics. 3
• Consider Mediterranean-diet-oriented dietary modifications. 3
• Do not independently purchase over-the-counter eye drops, as many contain preservatives or vasoconstricting agents. 3