Empiric Therapy Regimens
Blepharitis can be classified as either (1) anterior eyelid margin blepharitis (predominant bacterial infection of the eyelids, with hard matted crusts) or (2) posterior eyelid margin blepharitis (typically meibomian gland dysfunction [MGD]). See the main blepharitis article for further description.
Symptoms of the blepharitis subtypes overlap, and most individuals with blepharitis present with symptoms that are worse in the morning, typically including eyelids that stick together, dry or watery eyes, and any degree of soreness, foreign body sensation, itchiness, burning, or redness. The treatment of blepharitis can, for all intent, be interchanged between the different subtypes and follows a graded approach, with eyelid hygiene as its foundation.
For empiric treatment, eyelid hygiene with our without topical antibiotics is typically initiated. If there is no improvement after a few months or if the condition is particularly severe, oral antibiotics are added. Omega-3 fatty acids may also be recommended in all patients
Eyelid hygiene
Eyelid hygiene is the necessary foundation of blepharitis treatment and is typically recommended to all patients as initial management. Eyelid hygiene requires patient education and commitment to ensure compliance. Patients need to be informed that blepharitis is a chronic condition and that treatment must be continued despite symptom improvement.
Warm compresses
A face cloth can be soaked in warm water and then placed on top of closed eyelids for 5-10 minutes, 1-2 times daily. This helps to soften dried discharge and warm meibomian gland secretions.
Note: warm compresses are more useful in patients with posterior blepharitis, while eyelid cleansing may be more useful in patients with anterior blepharitis. However, clinicians typically recommend that patients with blepharitis commence with both of these.
Eyelid cleansing and massage
Patients can be instructed to use no-tear baby shampoo to gently massage the eyelid margins with their fingers, usually immediately after they have finished their evening application of warm compresses. Numerous commercially marketed products can also be used for eyelid cleansing, including Systane Lid Wipes, OCuSOFT Lid Scrubs, and related products. These products are more expensive than baby shampoo but may be easier to use and are preferred by some patients.
Topical antibiotic therapy
Topical antibiotic therapy is most useful in patients with anterior staphylococcal blepharitis but may be tried empirically by patients with general symptoms of the condition. A trial of ophthalmic erythromycin ointment or ophthalmic azithromycin solution may be instituted, 1-2 times a day for 2 weeks, and then tapered or discontinued after inflammation has improved. Ointments are preferred to drops, as ointments remain in contact with the lid margin for a longer period. However, ointments blur vision and so may be poorly tolerated during the day, in which case patients can be advised to use it only once before bedtime.
Oral antibiotic therapy
Patients with meibomian gland dysfunction (MGD) who do not respond to more conservative measures may benefit from systemic antibiotic therapy. Traditionally, tetracycline derivatives were the mainstays of treatment, but more recent studies have supported oral azithromycin as an effective alternative.
Doxycycline: Doxycycline is typically given 100 mg twice daily for about one month and then continued at 100 mg once daily for several months or indefinitely. Patients need to be counselled on the adverse effects of doxycycline, especially photosensitization and gastrointestinal upset. Doxycycline is contraindicated during pregnancy and in children younger than 8 years.
Minocycline: Minocycline is typically given 50 mg daily or twice daily.
Azithromycin: Azithromycin has been increasingly used as an effective alternative to the tetracyclines and is administered cyclically, 1 g each week for 3 weeks every 3-4 months.
Note: Ocular rosacea is a skin condition that frequently involves the eyes and is associated with meibomian gland dysfunction in up to 90% of cases. If untreated, rosacea blepharitis can progress to chalazia, corneal infiltrates, sterile ulcers, episcleritis, or anterior uveitis. The treatment of rosacea blepharitis focuses on the systemic and ocular diseases. The mainstay of treatment is oral antibiotic therapy as described above (doxycycline, minocycline, or azithromycin).
Omega-3 fatty acids therapy
Omega-3 fatty acids in pill or dietary form can be recommended to patients with chronic blepharitis. A 2008 study showed that patients who took two 1000-mg capsules of omega-3 fatty acids 3 times daily reported significantly improved blepharitis symptoms,
while a 2013 study showed that patients with dry eyes who took omega-3 supplementation reported significant improvement.
Treatment of concurrent dry eye
Patients with blepharitis frequently have evaporative and aqueous tear deficiency, so artificial tears may be helpful in some patients. Regular (preserved) artificial tears such as Refresh or Systane Ultra can be recommended for use up to 4 times a day.
Tea tree oil therapy
A 2012 study has correlated the concentration of Demodex, a parasitic mite, with the severity of blepharitis and found that treatment with tea tree oil significantly improved symptoms.
Some clinicians have since been advocating for the use of tea tree oil scrubs in the treatment of blepharitis.
Topical steroid therapy
Topical steroids should be used only for the most severe cases and should be prescribed only by ophthalmologists who will closely monitor the patient. If steroids are given, they should be in a brief course of topical drops, such as fluorometholone (FML) or loteprednol (Lotemax), and quickly tapered as inflammation improves.
Topical cyclosporine therapy
In patients with more severe blepharitis, topical cyclosporine 0.05% has been shown to improve symptoms superior to a combined antibiotic and steroid regimen.
Like topical steroids, however, cyclosporine drops should be prescribed only by an ophthalmologist with close follow-up.