Blepharitis Treatment

• 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

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

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