What is the appropriate treatment for blepharitis?

Treatment of Blepharitis

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

First-Line Treatment: Eyelid Hygiene (All Patients)

Daily eyelid hygiene forms the foundation of blepharitis management and must be maintained long-term, as this is a chronic condition without definitive cure. 2, 1

Warm Compresses

• Apply warm compresses to closed 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
• Ensure compresses are not hot enough to burn the skin 1
• Warm compresses are particularly effective for posterior blepharitis/meibomian gland dysfunction 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 2, 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 meibomian gland secretions 1
• Maintain this regimen daily or several times weekly to control chronic symptoms 2, 1

Critical Patient Counseling

• Patients must understand that blepharitis is chronic and incurable; symptoms recur when treatment is discontinued 1, 3
• Treatment requires long-term commitment rather than expecting complete cure 1, 4
• Patients with neurotrophic corneas require careful counseling to avoid corneal epithelial injury during eyelid cleansing 2
• Patients with advanced glaucoma should avoid aggressive lid pressure during massage, as this may increase intraocular pressure 2

Second-Line Treatment: Topical Antibiotics (After 2-4 Weeks)

Add topical antibiotics if eyelid hygiene provides inadequate relief after 2-4 weeks of consistent first-line therapy. 1, 3

Topical Antibiotic Options

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks 2, 1
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms 2, 1
• Topical tobramycin/dexamethasone suspension may reduce symptoms, though evidence comes from uncontrolled manufacturer-sponsored studies 2
• Loteprednol etabonate 0.5%/tobramycin 0.3% suspension is safer than dexamethasone-containing products due to lower risk of intraocular pressure elevation and cataract progression 2

Important Antibiotic Considerations

• Rotate different antibiotic classes intermittently to prevent development of resistant organisms 2, 1
• Adjust frequency and duration based on severity and treatment response 2
• Long-term antibiotic use risks creating resistant organisms 1, 3

Third-Line Treatment: Oral Antibiotics (Refractory MGD)

For meibomian gland dysfunction patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 2, 1

Oral Antibiotic Regimens for Adults

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement 2, 1
• Azithromycin pulse regimen: 1 gram per week for 3 weeks, or 500 mg daily for 3 days in three cycles with 7-day intervals 1
• Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects 1

Oral Antibiotics for Special Populations

• Use oral erythromycin or azithromycin for women of childbearing age and children under 8 years to avoid tetracyclines 2, 1
• Pediatric erythromycin dosing: 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 2
• Pediatric azithromycin dosing: 5 mg/kg daily for 2 months 2

Azithromycin Safety Warning

• Azithromycin may cause cardiac rhythm irregularities, especially in patients with high baseline cardiovascular risk 3

Specialized Treatments for Specific Etiologies

Demodex Blepharitis

• Tea tree oil at 50% concentration can be considered for patients not improving with previous treatments 1, 3, 4
• Metronidazole and ivermectin are alternative antiparasitic options 1
• Lotilaner ophthalmic solution 0.25% is the first FDA-approved therapy for Demodex blepharitis, eradicating mites in 50-67% of patients with benefits continuing through 1 year 5
• Intense pulsed light therapy shows high Demodex eradication rates but should be used cautiously in darkly pigmented individuals (above Fitzpatrick skin type IV) 4

Dry Eye Disease Management

• Topical perfluorohexyloctane (FDA-approved 2023) prevents tear evaporation and improves symptoms and corneal staining after 8 weeks 2, 1
• 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

Selenium Sulfide for MGD

• Selenium sulfide breaks disulfide bonds to unblock meibomian gland orifices and decrease meibum viscosity 2
• Phase 2 clinical trial showed significant improvements in glands secreting meibum and Ocular Surface Disease Index scores compared to vehicle 2

In-Office Procedures for Recalcitrant Cases

• Vectored thermal pulsation can be considered for refractory cases 1, 3, 4
• Microblepharoexfoliation may be used for persistent disease 1, 3
• Physical heating and expression of meibomian glands can be performed 1
• Intense pulsed light therapy and/or thermopulsation therapy are available options 1

Adjunctive Therapies

Corticosteroids

• Short course of topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 3
• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration 3
• Long-term low-dose topical steroids reserved only for patients with autoimmune diseases or moderate to severe dry eye disease 1
• Stronger potency steroids such as betamethasone may be needed for severe cases 1

Immunomodulators and Supplements

• Cyclosporine topical may be useful in posterior blepharitis and can help manage coexisting aqueous tear deficiency 3
• Omega-3 fatty acid supplements show mixed evidence but may improve tear break-up time and meibum score 1, 3

Critical Red Flag: Malignancy in Elderly Patients

Sebaceous carcinoma must be suspected in elderly patients with unresponsive, chronic, unilateral blepharitis or recurrent chalazia in the same location. 4

Red Flags Requiring Biopsy

• Nodular mass, ulceration, extensive scarring, lash loss, or localized crusting and scaling 4
• Unilateral disease unresponsive to standard therapy 4
• Recurrent chalazia in the same location 4

Special Population Considerations

Rosacea Patients

• Patients with rosacea commonly have associated blepharitis and require more aggressive management 3
• Rosacea patients often require systemic therapy with oral antibiotics 3

Preoperative Management

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

Follow-Up Strategy

• Visit intervals are dictated by severity of symptoms and signs, current therapy, and comorbid factors such as glaucoma in patients treated with corticosteroids 4
• Patients with mild blepharitis should return if their condition worsens 4
• Follow-up visits should include interval history, visual acuity measurement, external examination, and slit-lamp biomicroscopy 4