Blepharitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sujit Routray, M.D. [2]

Overview

Eyelid hygiene and regular cleaning are the mainstay of therapy for blepharitis. Antimicrobial topical therapy may be indicated in some cases depending on the causative pathogen and the underlying cause.

Medical Therapy

Eyelid Hygiene

Eyelid hygiene and regular cleaning are the mainstay of therapy for blepharitis. As blepharitis is a chronic disease, eyelid hygiene and regular cleaning must be performed even after an acute exacerbation has resolved. Common eyelid hygiene and cleaning techniques include:

• Warm compresses (heat can liquefy the abnormal solidified meibomian secretions and increase the quantity of secretions).
• Lid massage (massage may help empty the meibomian glands and improve secretion)
• Lid washing (gentle washing of the lashes and eyelid margins with warm water, eyelid scrub solutions, or baby shampoo to remove the accumulated material)

Antimicrobial topical therapy may be indicated in some cases depending on the causative pathogen and the underlying cause. It is important to consider eyelid margin hygiene before applying the topical therapy.

Antimicrobial Regimens

• 1. Empiric antimicrobial therapy

• Blepharitis

• Preferred regimen: Azithromycin 1% ophthalmic solution bid for 2 days followed by qd for 12-26 days
• Alternative regimen (1): Tobramycin/Dexamethasone 0.3%/0.05% ophthalmic suspension qid for 2 weeks
• Alternative regimen (2): Bacitracin ophthalmic ointment qhs for 2 weeks OR Bacitracin/Polymyxin B Sulfate ophthalmic ointment bid to qid for 2 weeks
• Alternative regimen (3): Erythromycinophthalmic ointment qhs for 2 weeks
• Alternative regimen (4): Metronidazole 2% gel bid for 1-2 weeks
• Note: Cyclosporine 0.05% ophthalmic emulsion bid for 6 months may be helpful in some cases of posterior blepharitis

• 2. Specific considerations

• 2.1 Meibomian gland dysfunction:

• Preferred regimen: Doxycycline 100 mg PO qd until clinical improvement followed by 40 mg PO qd for 2-6 weeks OR Minocycline 100 mg PO qd until clinical improvement followed by 50 mg PO for 2-6 weeks OR Tetracycline 1000 mg PO until clinical improvement followed by 250-500 mg PO qd for 2-6 weeks.
• Alternative regimen (1): Erythromycin 250-500 mg PO qd for 3 weeks OR Azithromycin 250-500 mg PO 1-3 times a week for 3 weeks OR Azithromycin 1 g PO once per week for 3 weeks
• Note: Tetracyclines are contraindicated among pregnant women, nursing women, and young children < 8 years of age

• 2.2 Dry eye

• Preferred regimen: Cyclosporine 0.05% ophthalmic emulsion bid for 6 months

• 2.3 Ocular Rosacea

• Preferred regimen: Doxycycline 100 mg PO qd until clinical improvement followed by 40 mg PO qd for 2-6 weeks OR Minocycline 100 mg PO qd until clinical improvement followed by 50 mg PO for 2-6 weeks OR Tetracycline 1000 mg PO until clinical improvement followed by 250-500 mg PO qd for 2-6 weeks OR (Azithromycin 250-500 mg PO 1-3 times a week for 3 weeks AND Tacrolimus 0.1% topical bid for 3 weeks) OR (Azithromycin 1 g PO once per week for 3 weeks AND Tacrolimus 0.1% topical bid for 3 weeks)

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Staphylococcus spp.

• Preferred regimen: Bacitracin ophthalmic ointment qhs for 2 weeks OR Bacitracin/Polymyxin B Sulfate ophthalmic ointment bid to qid for 2 weeks OR Erythromycinophthalmic ointment qhs for 2 weeks OR Azithromycin 1% ophthalmic solution bid for 2 days followed by qd for 12-26 days OR Tobramycin/Dexamethasone 0.3%/0.05% ophthalmic suspension qid for 2 weeks

• 3.2 Demodex folliculorum

• Preferred regimen: Metronidazole 2% gel bid for 1-2 weeks
• Alternative regimen: Ivermectin 200 microgram/kg once weekly for 2 weeks