• Early detection & appropriate management can reduce signs & symptoms of blepharitis & prevent permanent structural damage & possible loss of visual function
• Treatment options are often used in combination

Goals of Treatment

• To alleviate signs & 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 & 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 & Erythromycin are effective agents for initial therapy
  • Neomycin, Tobramycin & Gentamicin have been recommended for chronic therapy

• Ophthalmic solutions (eg Azithromycin)
  
  • Improves secretions of the meibomian gland & decreases redness in the eyelid

• Frequency & duration of treatment is based on the severity of blepharitis & response to treatment

Systemic Anti-infectives

• Tetracyclines (eg Doxycycline, Minocycline)
  
  • Decrease keratinization & lipase production in Staphylococcus epidermidis & Staphylococcus aureus
  • Used in patients w/ meibomian gland dysfunction (MGD) whose chronic symptoms are not adequately controlled w/ eyelid hygiene & in patients w/ ocular manifestations of rosacea
  • Given daily & 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 w/ eyelid or ocular surface inflammation (eg severe conjunctival injection, marginal keratitis, or phlyctenules)
• Tobramycin/Dexamethasone ophthalmic suspension & Azithromycin in a sustained release system showed reduction in the signs & 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 & discontinued once the inflammation is controlled & used intermittently to maintain patient comfort
• Use the lowest effective dose & avoid long-term use in order to minimize side effects [eg elevated intraocular pressure (IOP), cataract, & exacerbate the infectious process] that may lead to superinfection
  • Site-specific corticosteroids (eg Loteprednol etabonate) & corticosteroids w/ limited ocular preparation (eg Fluorometholone) can reduce the adverse effects

Topical Cyclosporine

• May be helpful in posterior blepharitis & w/ coexisting dry eye syndrome

Ivermectin

• Showed to be effective in some cases of recalcitrant Demodex blepharitis

Eyelid hygiene

• Includes warm compresses, eyelid massage & 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 & 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

• Clean the eyelid by gently rubbing the base of the eyelashes & lid margin w/ 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