Blepharitis Organism-Specific Therapy

Blepharitis is a common chronic inflammation of the eyelid margin found in all ethnicities, genders, and age groups, though more common in those over the age of 50.[1]  Clinically, there is irritation of the eyelid margins as well as flaking/crusting at the base of the eyelashes. Generally symptoms may include ocular burning, irritation, and foreign body sensation. It can be commonly associated with systemic conditions such as rosacea and seborrheic dermatitis.

Blepharitis can be classified as anterior, posterior, or marginal (combination of anterior and posterior) blepharitis.

Anterior blepharitis generally is caused by low-grade infections, primarily with Staphylococcus epidermidis or Staphylococcus aureus, but also with Propionibacterium acnes or corynebacteria. The eyelid margin may have erythema and edema. More chronic cases reveal telangiectasia on the eyelid margin, collarettes around the base of the eyelashes, and sometimes madarosis.

Posterior blepharitis generally is caused by meibomian gland dysfunction or rosacea. Meibomian glands often are obstructed and capped with oil. Posterior blepharitis often is associated with dry eyes and tear hyperosmolarity. Chronic posterior blepharitis is associated with structural changes of the meibomian gland ducts.

Marginal blepharitis can be caused by Demodex infestation or Phthirus pubis (crab lice) infestation. Demodex folliculorum generally is found at the base of the eyelashes and is common in anterior blepharitis. Demodex brevis is found in the meibomian glands and is common in posterior blepharitis. 

Long-term daily eyelid margin hygiene is the main treatment for blepharitis, although additional pharmacologic treatments may be added for each of the various types, depending on the causative organism(s).

Warm compresses/lid hygiene

Warm compresses aid with the unclogging of the meibomian glands. A clean wet washcloth should be heated (and frequently reheated with a microwave) to 104-110°F and rested on closed eyes directly at the eyelid margin for a minimum of 10 minutes (up to 15-20 minutes in severe cases). The heat opens the meibomian gland pores and melts the clogged oils.

With the same wash cloth, scrub the base of the eyelashes to express the meibomian glands and to remove any scurf, collarettes, and crusting.

This procedure should be repeated twice a day until the blepharitis has resolved though this often is chronic. 

Commercially made eyelid masks (eg, Bruder mask) that can be microwaved or electrically heated can help maintain the heat on the eyelids for more consistent and longer periods of time.

Anterior blepharitis - Pharmacological treatment for staphylococcal infection

Pharmacologic treatments for anterior staphylococcal blepharitis include the following:

• Bacitracin ophthalmic ointment applied to lid margin qid for 1-2 weeks or
• Erythromycin ointment applied to lid margin qid for 1-2 weeks or
• Azithromycin ophthalmic drops bid for 3 days then once daily for 27 days ^[2] or
• Tobramycin 0.3%/loteprednol etabonate 0.5% ophthalmic suspension qid in each eye for 2 weeks ^[3] or
• Tobramycin 0.3%/dexamethasone 0.1% ophthalmic solution qid in each eye for 2 weeks or
• Avenova eyelid scrub (hypochlorous acid 0.01%, Nova Bay Pharmaceuticals) bid in each eye

Posterior blepharitis - Pharmacologic treatment for meibomian gland dysfunction and rosacea

Pharmacologic treatments for posterior blepharitis due to meibomian gland dysfunction and rosacea include the following:

• Doxycycline PO 50 g/day for 3-6 months ^[4] or
• Minocycline PO 50 mg bid for 2 months ^[5] or
• Azithromycin PO 500 mg/day for 2 weeks or
• Cyclosporin ophthalmic solution bid in each eye for 1 year ^[6]   or
• Omega 3 essential fatty acids PO 1000 mg/day

Marginal blepharitis - Pharmacologic treatment for Demodex infections

Pharmacologic treatments for marginal blepharitis due to Demodex infections include the following:

• Lotilaner ophthalmic (Xdemvy): 1 drop in each eye BID for 6 weeks ^{[8, 9]}  
• Tea tree oil 5% daily eyelid scrub for 6 weeks or
• Cliradex eyelid wipe bid in each eye for 6 weeks ^[7]