What is the treatment for 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

Algorithmic Treatment Approach

Step 1: First-Line Conservative Management (All Patients)

Warm Compresses:

• Apply warm compresses to closed 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
• This softens crusts and warms meibomian gland secretions, particularly effective for posterior blepharitis/meibomian gland dysfunction 1
• Critical caveat: Ensure compresses are not hot enough to burn the skin 1
• Patients with advanced glaucoma should avoid aggressive lid pressure during massage as this may increase intraocular pressure 1

Eyelid Hygiene:

• Gently rub the base of eyelashes using diluted baby shampoo or commercially available eyelid cleaners on a cotton swab, pad, or clean fingertip 1
• Hypochlorous acid 0.01% eye cleaners provide strong antimicrobial effects for both anterior and posterior blepharitis 1
• For meibomian gland dysfunction, perform vertical eyelid massage to express gland secretions 1
• This regimen must be maintained daily or several times weekly long-term, as blepharitis is chronic and incurable—symptoms recur when treatment stops 1

Adjunctive Measures:

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

Step 2: Second-Line Topical Antibiotics (After 2-4 Weeks if Inadequate Response)

Standard Topical Therapy:

• Apply bacitracin or erythromycin ointment to eyelid margins once daily or at bedtime for several weeks 1, 2
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 1
• For ulcerative blepharitis specifically: Initiate topical antibiotics earlier and more aggressively due to bacterial infection and higher risk of permanent structural damage including eyelash loss, lid scarring, and corneal scarring 3

Important Antibiotic Considerations:

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 1
• Adjust frequency and duration based on severity and treatment response 1
• Long-term antibiotic use risks creating resistant organisms 1, 2

Step 3: Third-Line Oral Antibiotics (For MGD with Inadequate Response to Topical Therapy)

Adult Regimens:

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

Alternative Regimens (Women of Childbearing Age and Children <8 Years):

• Oral erythromycin 1, 4
• 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
• Caution: Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 2

Step 4: Specialized Treatments for Refractory Cases

Demodex Blepharitis:

• Tea tree oil at 50% concentration for patients not improving with previous treatments 1, 2
• Alternative antiparasitic options include metronidazole and ivermectin 1

Advanced In-Office Procedures:

• Vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 1, 2
• Physical heating and expression of meibomian glands 1
• Intense pulsed light therapy and/or thermo pulsation therapy 1

Additional Adjunctive Therapies:

• Topical perfluorohexyloctane to prevent tear evaporation and improve dry eye symptoms 1, 2
• Short course of topical corticosteroids (loteprednol etabonate or fluorometholone phosphate preferred) for marked eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 2, 3
• Topical cyclosporine may be useful for posterior blepharitis with 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 Patient Education Points

Essential Counseling:

• 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

Preoperative Patients:

• Those with moderate to severe blepharitis should receive topical antibiotics and intensive eyelid hygiene before intraocular surgery to reduce endophthalmitis risk 1, 3
• Blepharitis is a risk factor for endophthalmitis after intravitreal injection and bleb-related infection 1

High-Risk Patients:

• Patients with neurotrophic corneas should be counseled carefully to avoid corneal epithelial injury during eyelid cleansing 1, 3

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