Approach

Blepharitis is usually a chronic condition for which symptomatic control is the mainstay of treatment. Not uncommonly, symptoms may be secondary to another condition (e.g., eczema, rosacea). Treatment of any underlying disease is essential to resolve blepharitis.

Initial therapy

Explain to the patient that a cure is not usually possible, but that symptoms can be lessened by using prescribed treatments consistently.[1] This should include eyelid hygiene, omega-3 fatty acid supplementation, and treatments for dry eye disease.

Eyelid hygiene measures

Eyelid hygiene measures are the initial and maintenance treatment for blepharitis.[1][37]​​​​​ Warm compresses are applied to the eyelid for 5-10 minutes twice daily, aiming to aid expression by raising the temperature above the melting point of meibum. However, an expert panel deemed that this approach may be of limited value in patients with Demodex blepharitis.[36]​

Eyelid scrubs, used to clear away the scales on lashes, improve both patient-reported symptoms and clinical findings.[38] Eyelid massage is thought to help express meibomian gland secretions and improve capping of the gland orifices. In-office procedures to unclog the meibomian glands using thermal pulsation or mechanical means are available, but they have not been assessed in randomised controlled trials.

Omega-3 fatty acid dietary supplementation

Some patients may benefit from supplementation, but evidence is conflicting.[1] One study found an improvement in tear film break-up time, dry eye symptoms, and meibum score after 1 year of omega-3 fatty acid supplementation, but a subsequent trial found no significant improvement over placebo.[39][40]

Treating dry eye syndrome

Assess and treat associated dry eye syndrome with either artificial tears or topical ophthalmic ciclosporin.[41] Compared with artificial tears, ciclosporin improves ocular symptoms, lid margin vascular injection, tarsal telangiectasis, and fluorescein staining while decreasing meibomian gland inclusions.[42] However, it has shown mixed results in other studies.[43]

One Cochrane review found that there is no high quality evidence to support the efficacy and safety of topical treatments for blepharitis in children (e.g., corticosteroids and antibiotics in combination for children with blepharokeratoconjunctivitis).[44]

Refer patients with more severe blepharitis to an ophthalmologist for additional measures (e.g., punctal plugs or cauterisation).

See Dry eye disease.

Unresponsive to initial therapies

Patients with blepharitis unresponsive to initial therapies can be treated with topical antibiotics, corticosteroids, or antiparasitic agents.

Topical antibiotic

Erythromycin or bacitracin ophthalmic ointments are effective against staphylococcal isolates.[45]

Some specialists recommend azithromycin ophthalmic solution as a second-line option for meibomian gland dysfunction. Although data conflict on the use of azithromycin for this purpose, one systematic review and meta-analysis concluded that topical therapy improved symptoms, signs, and tear-film stabilisation, at least in the short-term.[43][46]​​​

It is usual to discontinue treatment after a few weeks once the acute symptoms resolve. If longer-term treatment is required the patient should be referred to an ophthalmologist due to the risk of adverse effects. Cultures can be useful if blepharitis remains unresponsive.

Topical ophthalmic corticosteroid

In the acute inflammatory phase, especially if marginal keratitis or corneal phlyctenules are present, consider a short course of a topical ophthalmic corticosteroid. Topical corticosteroids may prevent recurrent corneal erosions associated with ocular rosacea when given with oral doxycycline.[47] Taper therapy after symptoms resolve and avoid long-term corticosteroid use, where possible, due to the risks of cataract, superinfection, and glaucoma.

Topical antiparasitic therapy

A Delphi panel (Demodex Expert Panel on Treatment and Eyelid Health) concluded that collarettes may be considered pathognomonic for Demodex blepharitis and that patients with >10 collarettes should be treated, even in the absence of symptoms.[48] However, the Delphi panel failed to reach a consensus on how to grade the severity of Demodex blepharitis.[36]

Tea tree oil or metronidazole lid scrubs may be used to treat Demodex blepharitis.[1][49][50] Use low-concentration tea tree oil to avoid risk of damage to the corneal epithelium.[1][51]​​​​​​​

Delphi methodology failed to establish a consensus regarding the best treatment for Demodex blepharitis, but determined that heat, including warm compresses, is not generally useful.[36]​

Clinical trials, published subsequent to the Delphi panel, have found that topical lotilaner solution applied for 6 weeks significantly reduces collarettes, is associated with increased mite eradication, and reduces eyelid erythema compared with a vehicle control.[1][52][53]​​​​[54]

Unresponsive to topical antibiotics or corticosteroids or antiparasitics

Guidelines suggest that patients with meibomian gland dysfunction with chronic symptoms and signs (not adequately controlled by eyelid cleansing or meibomian gland expression) may benefit from the addition of an oral antibiotic (typically a tetracycline or a macrolide) to existing therapy.[1][37] However, one 2021 Cochrane review found insufficient evidence to draw meaningful conclusions on the use of oral antibiotics for chronic blepharitis, and suggested that further research is needed in this area.[55]​​​​​

Tetracyclines are known to cause hepatotoxicity and haemolytic anaemia, and they should not be used in pregnant or lactating women due to the risk of tooth enamel abnormalities in the baby.[5][56]​​​ Oral erythromycin or azithromycin are alternatives for women of childbearing age, but care should still be taken with oral azithromycin due to its potential to trigger irregular heart rhythms.[1]

Tetracyclines and macrolides are effective in treating acne rosacea, which is frequently associated with posterior blepharitis. Patients with systemic rosacea may require treatment with topical azelaic acid, topical ivermectin, brimonidine, doxycycline, or isotretinoin.[37] 

Visual impairment

Chronic suppressive oral antibiotic therapy is indicated in patients with visual impairment. Tetracyclines are the preferred antibiotics, except in pregnant and lactating women.

Oral doxycycline has been shown to improve clinical outcomes in several studies.[43] Corneal changes such as vascularisation and scarring may benefit from a short course of a topical corticosteroid. In patients with corneal inflammation not responding to oral antibiotics with or without topical corticosteroids, topical ophthalmic ciclosporin has been shown to reduce meibomian gland dysfunction.[42]

Ophthalmology referral

Referral to appropriate healthcare professionals may be necessary depending on the presentation.[1]​ The American Academy of Ophthalmology supports the prompt and appropriate referral of individuals to an ophthalmologist when they present with visual impairment, including that due to inflammation of the lids or conjunctiva, with or without discharge.[57]​

Corneal ulceration and perforation requires management with aggressive antibiotic therapy, glue, or surgery. Atypical, unilateral, or non-responsive eyelid margin inflammation (e.g., loss of eyelashes, extensive scarring) requires the exclusion of an eyelid tumour or an immune-mediated disease.[1]​​

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