Blepharitis Treatment
Principles of Therapy
- Early detection and appropriate management can reduce signs and symptoms of blepharitis and prevent permanent structural damage and possible loss of visual function
- Treatment options are often used in combination
Goals of Treatment
- To alleviate signs and symptoms
- To reduce risk of structural damage
- To prevent permanent loss of vision
Pharmacotherapy
Topical Anti-infectives
- Ointments (eg Bacitracin, Erythromycin, Neomycin, Tobramycin, Gentamicin)
- Helps to reduce the bacterial load of the eyelashes and conjunctiva
- Placed on the lid margin up to 4 times a day or once at bedtime
- Should be applied in the lid margin to avoid ocular surface toxicity
- Bacitracin and Erythromycin are effective agents for initial therapy
- Neomycin, Tobramycin and Gentamicin have been recommended for chronic therapy
- Ophthalmic solutions (eg Azithromycin)
- Improves secretions of the meibomian gland and decreases redness in the eyelid
- Frequency and duration of treatment is based on the severity of blepharitis and response to treatment
- Application may be repeated intermittently using different agents with different mechanisms of action to prevent development of bacterial resistance
Systemic Anti-infectives
- Tetracyclines (eg Doxycycline, Minocycline)
- Decrease keratinization and lipase production in Staphylococcus epidermidis and Staphylococcus aureus
- Used in patients with MGD whose chronic symptoms are not adequately controlled with eyelid hygiene and in patients with ocular manifestations of rosacea
- Given daily and tapered after clinical improvement is noticed usually 2-6 weeks
- Can be given also in intermittent courses depending on the exacerbation of symptoms
- Macrolides (eg Erythromycin, Azithromycin) have anti-inflammatory activity
- Oral Azithromycin is an alternative to oral tetracyclines for blepharitis
Topical Corticosteroids
- Brief course of corticosteroids can be used in patients with eyelid or ocular surface inflammation (eg severe conjunctival injection, marginal keratitis, or phlyctenules)
- Tobramycin/Dexamethasone ophthalmic suspension and Azithromycin in a sustained release system showed reduction in the signs and symptoms of blepharitis
- Corticosteroid eye drops or ointments are applied several times a day to the eyelids or ocular surface for no more than 2 weeks
- Can be tapered and discontinued once the inflammation is controlled and used intermittently to maintain patient comfort
- Use the lowest effective dose and avoid long-term use in order to minimize side effects [eg elevated intraocular pressure (IOP), cataract, and exacerbate the infectious process] that may lead to superinfection
- Site-specific corticosteroids (eg Loteprednol etabonate) and corticosteroids with limited ocular preparation (eg Fluorometholone) can reduce the adverse effects
Topical Cyclosporine
- May be helpful in posterior blepharitis and with coexisting dry eye syndrome
Ivermectin
- Showed to be effective in some cases of recalcitrant Demodex blepharitis
Non-Pharmacological Therapy
Eyelid Hygiene
- Includes warm compresses, eyelid massage and scrubs
- Can be done once or twice daily
Warm Compresses
- Applying/placing warm cloth on closed eyelids for 5-10 minutes
- Softens adherent encrustations, liquefies the solidified sebum in the meibomian ducts and dilate the ducts
- Use hot tap water on a clean cloth or heated gel pack for sustained warmth
- Helpful as initial treatment for posterior blepharitis
Eyelid Massage
- Brief, gentle massage of the eyelids done immediately after warm compresses
- Meibomian secretions can be expressed by vertical eyelid massage
- Removal of crusting from the eyelashes can be achieved by horizontally rubbing the eyelid margins
- Ensure that the patient has the necessary skill to perform the above maneuvers safely
- The washcloth used in the warm compresses or a clean fingertip may be used during the massage
- Very useful as initial treatment for anterior blepharitis
Eyelid Scrubs/Washing
- Clean the eyelid by gently rubbing the base of the eyelashes and lid margin with diluted baby shampoo (1:10 in water) or eyelid cleaner on a pad, cotton ball, cotton swab, or clean fingertip
- Avoid vigorous rubbing/washing as it can further cause irritation