Blepharitis medical therapy: Difference between revisions

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{{Blepharitis}}
{{Blepharitis}}
{{CMG}}
{{CMG}} {{AE}} {{SR}}
==Medical Therapy==
==Medical Therapy==
The single most important treatment principle is a daily routine of lid margin hygiene as described below. Such a routine needs to be convenient enough to be continued lifelong to avoid relapses as blepharitis is a lifelong condition. 


'''A typical lid margin hygiene routine consists of 3 steps:'''<br />
::*'''1. Empiric antimicrobial therapy'''<ref>{{cite web | url = http://www.aao.org/preferred-practice-pattern/blepharitis-ppp--2013 | title = Blepharitis PPP 2013}}</ref>
'''1. Softening of lid margin debris and oils:'''<br />
:::*'''Blepharitis'''
Apply a warm wet compress to the lids - such as a washcloth with hot water - for about 2 minutes.
::::*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
'''2. Mechanical removal of lid margin debris:'''<br />
::::*Alternative regimen (2): [[Bacitracin]] ophthalmic ointment qhs for 2 weeks {{or}} [[Bacitracin]]/[[Polymyxin B Sulfate]] ophthalmic ointment bid to qid for 2 weeks
At end of shower routine, wash your face with a wash cloth. Use facial soap or non-burning baby shampoo (make sure to dilute the soap solution 1/10 with water first). Gently and repeatedly rub along the lid margins while eyes are closed.
::::*Alternative regimen (3): [[Erythromycin]]ophthalmic ointment qhs for 2 weeks
   
::::*Alternative regimen (4): [[Metronidazole]] 2% gel bid for 1-2 weeks
'''3. Antibiotic reduction of lid margin bacteria (at the discretion of your physician):<br />
::::*Note: [[Cyclosporine]] 0.05% ophthalmic emulsion bid for 6 months may be helpful in some cases of posterior blepharitis
After lid margin cleaning, spread small amount of prescription antibiotic ophthalmic ointment with finger tip along lid fissure while eyes closed. Use prior to bed time as opposed to in the morning to avoid blurry vision. <br />
::*'''2. Specific considerations'''
   
:::*'''2.1 Meibomian gland dysfunction''':
The following guide is very common but is more challenging to perform by visually disabled or frail patients as it requires good motor skills and a mirror. Compared to above it does not bear any advantages:<br />
::::*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.
1. Apply hot compresses to both eyes for 5 minutes once to twice per day.
::::*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}} [[Erythromycin]]ophthalmic 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


2. After hot compresses, in front of a mirror, use a moist Q-tip soaked in a cup of water with a drop of baby shampoo. Rub along the lid margins while tilting the lid outward with the other hand.
3. In front of mirror, place small drop of antibiotic ophthalmic ointment (e.g. [[erythromycin]]) in lower conjunctival sack while pulling lid away from eye with other hand. <br />
   
Often the above is advised together with mild massage to mechanically empty glands located at the lid margin ([[Meibomian glands]], [[glands of Zeis|Zeiss glands]], [[glands of Moll|Moll glands]]). <!--
  --><ref name="Moorfield">[http://www.moorfields.nhs.uk Moorfields eye hospital] ([[United Kingdom|UK]]) Patient information leaflet: [http://members.aol.com/MedikInfo/MI_Ophth_Blepharitis_Moorfields.doc Blepharitis - Lid Hygiene Advice For Patients]</ref>
Depending on the degree of inflammation of the lid margin, a combination of topical antibiotic and steroid drops or ointments can be prescribed to provide instant relief. However, this harbors significant risks such as increased intraocular pressure and posterior subcapsular [[cataract]] formation. Since cataract formation is irreversible and even intraocular hypertension might be (harboring the risk of [[glaucoma]] with permanent visual loss), both need to be checked for monthly. Steroid-induced cataracts and ocular hypertension can affect all ages.
If [[acne rosacea]] coexists, treatment should be focused on this skin disorder as the underlying cause together with the above lid margin hygiene routine. Typically, 100 mg [[doxycycline]] by mouth twice per day is prescribed for four to six weeks which can be tapered to 50 mg once daily for several years. Some physicians use a lower starting dose. Patients are instructed to continue use for at least two months before symptoms improve significantly. Contrary to common belief, use of tetracycline-type antibiotics is not primarily to treat bacterial infection but rather to inhibit [[matrix metalloproteinases]] resulting in thinning of oil gland secretions and change of the characteristic prominent capillary pattern.
Dermatologists treat blepharitis similarly to seborrheic dermatitis by using safe topical anti-inflammatory medication like[[sulfacetamide]] or brief courses of a mild topical steroid.  Although anti-fungals like [[ketoconazole]] (Nizoral) are commonly prescribed for seborrheic dermatitis, dermatologists and optometrists usually do not prescribe anti-fungals for seborrheic blepharitis.
<!--
  --><ref name="JFrOphtalmol2005-Derbel">{{cite journal | author = Derbel M, Benzina Z, Ghorbel I, Abdelmoula S, Makni F, Ayadi A, Feki J | title = [Malassezia fungal blepharitis: a case report] | journal = J Fr Ophtalmol | volume = 28 | issue = 8 | pages = 862-5 | year = 2005 | id = PMID 16249768}}</ref>
'''4. Ocular Antihistamines and allergy treatments:<br />
If these conventional treatments for blepharitis do not bring relief, patients should consider allergy testing.  Allergic responses to dust mite feces and other allergens can cause lid inflammation, ocular irritation, and dry eyes.  Prescription optical antihistamines like Patanol, Optivar, Elestat, and over the counter optical antihistamines like Zaditor are very safe and can bring almost immediate relief to patients whose lid inflammation is caused by allergies.<br />
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 20:48, 11 August 2015

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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]

Medical Therapy

  • 1. Empiric antimicrobial therapy[1]
  • 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.
  • 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

References

  1. ↑ "Blepharitis PPP 2013".

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