Adult Blepharitis Treatment & Management

A systematic and long-term commitment to a program of eyelid margin hygiene is the basis of treatment of blepharitis. Clinicians must ensure that patients recognize that the management of blepharitis is a process, which must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a process in which a patient goes from physician to physician, seeking some panacea for this frustrating condition.^[4]

• Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps.

  • First, application of heat to warm the eyelid gland secretions and to promote evacuation and cleansing of the secretory passages is essential. Patients commonly are directed to use soaked warm compresses and to apply them to the lids repeatedly. Warm water in a washcloth, soaked gauze pads, or microwaved, soaked cloths can be used. Patients should be instructed to use extreme care and to avoid the use of excessive heat.
  • Second, the eyelid margin is washed mechanically to remove adherent material, such as scurf, collarettes, and crusting, and to clean the gland orifices. This can be completed with a warm washcloth or with gauze pads. Water often is used, although some clinicians prefer that a few drops of baby shampoo be mixed in one bottle cap full of warm water to form a cleaning solution. Attention must be directed to gentle mechanical jostling or scrubbing of the eyelid margin itself, not the skin of the lids or of the bulbar conjunctival surface. Vigorous scrubbing is not necessary and may be harmful.
  • Third, an antibiotic ointment is applied to the eyelid margin after it has been soaked and scrubbed. Commonly used agents include erythromycin or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although their use is less appropriate for long-term management.
• Specific clinical situations may require additional treatment. Refractory cases of blepharitis often respond to oral antibiotic use. One- or two-month courses of tetracycline often are helpful in reducing symptoms in patients with more severe disease. Tetracycline is believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole is being studied.
• Tear film dysfunctions can prompt use of artificial tear solutions, tear ointments, and closure of the puncta. Associated conditions, such as herpes simplex, varicella-zoster, or staphylococcal skin disease, can require specific antimicrobial therapy based on culture. Seborrheic disease is often improved by the use of shampoos with selenium, although its use around the eyes is not recommended. Allergic dermatitis can respond to topical corticosteroid therapy.
• Conjunctivitis and keratitis can result as a complication of blepharitis and require additional treatment besides eyelid margin therapy. Antibiotic-corticosteroid solutions can greatly reduce inflammation and symptoms of conjunctivitis. Corneal infiltrates also can be treated with antibiotic-corticosteroid drops. Small marginal ulcers can be treated empirically, but larger, paracentral, or atypical ulcers should be scraped and specimens sent for diagnostic slides and for culture and sensitivity testing.
• Recurrent bouts of inflammation and scarring from blepharitis can promote eyelid positional disease. Trichiasis and lid notching can result in keratitis and severe symptoms. These conditions often are very refractory to simple management steps. Trichiasis is treated with epilation, destruction of the follicles via electric current, laser, or cryotherapy, or with surgical excision. Entropion or ectropion can develop and complicate the clinical situation and may require referral to an oculoplastics surgeon.

Surgical care for blepharitis is needed only for complications such as chalazion formation, trichiasis, ectropion, entropion, or corneal disease.

Patients with refractory acne rosacea may benefit from a consultation with a dermatologist.

Patients with poor nutrition may be at a higher risk for blepharitis.