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 not a cure but a process that must be carried out for prolonged periods of time. This understanding helps reduce "doctor shopping," a ceremony in which a patient goes from physician to physician, seeking some panacea for this frustrating condition. ^[9]

Many appropriate systems of eyelid hygiene exist, and all include variations of 3 essential steps, as follows:

• First, application of heat to warm the eyelid gland secretions, to bring the turbid lipid glandular material to its melting point and resultant liquification, 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. Many useful eyelid applicators are readily available and provide a more sterile application surface. Patients should be instructed to use care 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 cotton-tip applicators or gauze pads. Tap water is often mistakenly used, rather than normal saline or boiled distilled water. Many clinicians instruct patients to mix a few drops of baby shampoo with warm water to form a cleaning solution. Several useful commercially available cleansing preparations are also available, including Ocusoft (generic), lavender scrubs (Oasis), and hypochlorous acid (Avenova). 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 bacitracin, polymyxin B, erythromycin, or sulfacetamide ointments. Antibiotic-corticosteroid ointment combinations can be used for short courses, although, because of the risks associated with ocular steroids, 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 class agents often are helpful in reducing symptoms in patients with more severe disease and those with acne rosacea. Tetracycline, doxycycline, and minocycline are believed not only to reduce bacterial colonization but also to alter metabolism and reduce glandular dysfunction. The use of metronidazole and topical minocycline is being studied. ^{[1, 4, 10]}

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 or Elidel therapy. ^[5]

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 oculoplastic surgeon to repair the lid abnormality.

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

In addition, numerous new therapies are available, including the following:

Thermal pulsation therapy: the LipiFlow device (Tear Science) applies a homogenous temperature of 40.5 degrees C to both the anterior and posterior surface of the eyelids. Pulsations then mildly express the infected, inspissated and dead debris from the meibomian glands.

MiBoFlo is a thermal therapy applied to the outer lids in an office setting by a qualified technician.

BlephEx is a rotating light burr applied in office by a qualified technician that debrides the capped and inflamed meibomian orifice allowing for better flow of meibum and better results from other thermally based therapies, including home compresses.

The Maskin probe is a very fine stainless-steel tip applied to the thoroughly anesthetized inspissated meibomian gland orifice by an ophthalmologist. A very light electrical current is applied to facilitate the flow of meibum.

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.

Maintenance of a long-term regimen of lid hygiene helps prevent outbreaks of more symptomatic disease.

Patients with blepharitis usually are started on treatment, and they are seen in 2-6 weeks for a follow-up examination. During this visit, an assessment of the clinical response to therapy is made. The physician should again emphasize the necessity for a prolonged and dedicated course of treatment to the patient. Encouragement and support is critical in helping patients  become committed to the course of treatment and to follow it. Additionally, the clinician is able to keep the focus on rigorous intervention by the patient, rather than accepting blame for not curing the condition.

Patients are seen based on progress. If little improvement has been made after 1-2 months of treatment, intervention should be stepped up by prescribing antibiotic-corticosteroid ointments or oral antibiotics or by treating tear film dysfunction with such measures as punctal closure or thermal pulsation. Fluorescein staining of the cornea is recommended on each examination.