What is the recommended management for blepharitis?

Blepharitis Management

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 consistent lid hygiene. 1

Understanding the Condition

Blepharitis is a chronic inflammatory condition without a definitive cure—patients must understand that symptoms will recur when treatment is discontinued, making long-term management essential rather than expecting complete resolution. 2, 1 The disease divides anatomically into anterior blepharitis (affecting eyelid skin, lash base, and follicles) and posterior blepharitis/meibomian gland dysfunction (MGD, affecting meibomian glands). 3

First-Line Treatment: Lid Hygiene (All Patients)

Warm Compresses:

• Apply warm compresses to eyelids for several minutes once or twice daily to soften adherent crusts and warm meibomian secretions. 2, 1
• Use hot tap water on a clean washcloth, over-the-counter heat packs, or microwaveable bean/rice bags. 1
• Critical caveat: Instruct patients to avoid compresses hot enough to burn the skin. 2, 1
• Warm compresses are especially effective for posterior blepharitis/MGD. 2, 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, 3
• For MGD specifically, perform vertical eyelid massage to express meibomian gland secretions. 2, 1
• Rubbing the eyelid margins side-to-side removes crusting from eyelashes. 2

Important safety consideration: Assess the patient's manual dexterity and judgment before recommending digital massage, as improper technique can cause injury. 2

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

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

Preferred topical options:

• Bacitracin or erythromycin ointment applied to eyelid margins one or more times daily or at bedtime for several weeks. 1, 3, 4
• For blepharitis, all scales and crusts should be carefully removed before spreading ointment uniformly over lid margins. 4
• Azithromycin in sustained-release formulation has demonstrated efficacy in reducing signs and symptoms. 1, 3

Critical antibiotic stewardship: Rotate different antibiotic classes intermittently to prevent development of resistant organisms, as long-term antibiotic use risks creating resistant bacteria. 2, 1

Third-Line Treatment: Oral Antibiotics (Severe/Refractory MGD)

For MGD patients with inadequate response to eyelid hygiene and topical therapy, escalate to oral antibiotics. 1

Adult regimens:

• Doxycycline, minocycline, or tetracycline given daily, then tapered after clinical improvement. 1
• 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

Women of childbearing age and children under 8 years:

• Oral erythromycin or azithromycin (tetracyclines contraindicated). 1

Mechanism: Tetracyclines and macrolides provide both antimicrobial and anti-inflammatory effects. 1

Adjunctive Therapies

Artificial tears:

• Use preservative-free formulations for patients with poor ocular surface condition or those using drops more than 4 times daily. 1
• Consider lipid-containing supplements if MGD is present. 1

Anti-inflammatory agents:

• Short course of topical corticosteroids for eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules. 1
• Loteprednol etabonate and fluorometholone phosphate are safer options due to site-specific action and limited ocular penetration. 1
• Topical cyclosporine may be useful in posterior blepharitis and can help manage coexisting aqueous tear deficiency. 1

Demodex-specific treatment:

• Tea tree oil at 50% concentration for patients not improving with previous treatments. 1, 3
• Alternative antiparasitic options include metronidazole and ivermectin. 1

Advanced/In-Office Procedures (Recalcitrant Cases)

• Vectored thermal pulsation or microblepharoexfoliation for cases resistant to medical management. 1, 3
• Physical heating and expression of meibomian glands. 1
• Intense pulsed light therapy and/or thermo pulsation therapy. 1

Special Population Considerations

Preoperative patients:

• Address moderate to severe blepharitis with topical antibiotics and eyelid hygiene before intraocular surgery to reduce endophthalmitis risk, as causative organisms (coagulase-negative Staphylococcus, S. aureus, Streptococcus) are commonly associated with blepharitis. 2, 1

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

Patients with rosacea, atopy, psoriasis, or eczema:

• These patients commonly have associated blepharitis and may require more aggressive management, often necessitating systemic therapy with oral antibiotics. 3

Critical Patient Education

• Blepharitis is chronic and incurable; symptoms recur when treatment is discontinued. 2, 1, 3
• Long-term daily eyelid hygiene is essential for symptom control—this must be maintained indefinitely, not just during symptomatic periods. 1, 3
• Treatment requires persistence and often a trial-and-error approach to find the optimal regimen. 2
• Frequency and duration of treatment should be adjusted based on severity and treatment response. 1