What is the recommended treatment approach for a patient with blepharitis?

Treatment of Blepharitis

Begin with daily warm compresses and eyelid hygiene for all blepharitis patients, escalate to topical antibiotics (bacitracin or erythromycin) if symptoms persist after 2-4 weeks, and reserve oral antibiotics (doxycycline) for meibomian gland dysfunction unresponsive to topical therapy. 1

Algorithmic Treatment Approach

Step 1: First-Line Therapy (All Patients, 2-4 Weeks)

Warm Compresses:

• Apply 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
• This softens crusts and warms meibomian secretions, particularly effective for posterior blepharitis/meibomian gland dysfunction 1
• Avoid compresses hot enough to burn the skin 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, 2
• For meibomian gland dysfunction, perform vertical eyelid massage to express gland secretions 1, 2

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 Therapy (Inadequate Response After 2-4 Weeks)

Add Topical Antibiotics:

• Apply bacitracin or erythromycin ointment to eyelid margins one or more times daily or at bedtime for several weeks 1, 2, 3
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 1, 3
• Rotate different antibiotic classes intermittently to prevent resistant organisms 1

Important Caveat: Long-term antibiotic use risks creating resistant organisms, so adjust frequency and duration based on severity and treatment response 1, 2

Step 3: Third-Line Therapy (Meibomian Gland Dysfunction Unresponsive to Topical Treatment)

Oral Antibiotics:

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 1, 2, 3
• Alternative regimens for women of childbearing age and children under 8 years: oral erythromycin or azithromycin 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, 3

Critical Warning: 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, 3
• Alternative antiparasitic options: metronidazole and ivermectin 1
• Intense pulsed light therapy shows high Demodex eradication rate but use with caution in darkly pigmented individuals (above Fitzpatrick skin type IV) 3

In-Office Procedures:

• Vectored thermal pulsation or microblepharoexfoliation for recalcitrant cases 1, 2
• Physical heating and expression of meibomian glands 1

Additional Options:

• 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 eyelid or ocular surface inflammation 2
• Topical cyclosporine for posterior blepharitis with coexisting aqueous tear deficiency 2

Critical Patient Education

Set Realistic Expectations:

• Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued 1, 2, 3
• Long-term daily eyelid hygiene is essential for symptom control 1, 2, 3
• Treatment requires persistence and often a trial-and-error approach 1
• Symptoms can frequently be improved but are rarely eliminated 3

Special Population Considerations

Elderly Patients:

• Suspect sebaceous carcinoma in elderly patients with unresponsive, chronic, unilateral blepharitis or recurrent chalazia in the same location 3
• Red flags include nodular mass, ulceration, extensive scarring, lash loss, or localized crusting and scaling 3

Patients with Advanced Glaucoma:

• Advise against aggressive lid pressure during massage, as this may increase intraocular pressure 1

Patients with Neurotrophic Corneas:

• Counsel carefully to avoid corneal epithelial injury during eyelid cleansing 1

Preoperative Patients:

• Address moderate to severe blepharitis 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
• Air-conditioned environments increase dry eye disease risk 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
• Use moisture chamber spectacles/goggles for severe cases 1

Follow-Up Strategy

• Visit intervals are dictated by severity of symptoms and signs, current therapy, and comorbid factors 3
• Patients with mild blepharitis should return if their condition worsens 3
• Follow-up visits should include interval history, visual acuity measurement, external examination, and slit-lamp biomicroscopy 3