Pearls: Blepharitis Treatment Protocol
Pearls: Blepharitis Treatment Protocol
By Paul M. Karpecki, OD, FAAO
The following is my treatment protocol for anterior blepharitis:
The following is my treatment protocol for posterior blepharitis (meibomitis):
- Warm compresses for a minimum of 5 minutes, followed by lid cleaning and lid scrubs with a product such as OcuSoft Lid Scrub or OcuSoft Lid Scrub Plus. OcuSoft Lid Scrub Plus is non-toxic, leave-on cleanser that is appropriate for blepharitis caused by Demodex and advanced or very active staphylococcal infection.
- Topical drops that reduce bacterial count and inflammation. If there are signs of inflammation (redness and lid edema), my first choice is topical ophthalmic azithromycin (AzaSite®) daily following at least 5 minutes of hot compresses. I have patients place the drop on a clean index finger and apply to the lid margins.
- If lids do not show significant erythema/edema and cost is an issue, bacitracin or erythromycin ointment may be used. However, AzaSite appears to work significantly better than alternatives (Foulks et al., ARVO 2009) and is easier for patients than an ointment (which is messy and can get on pillowcases at night).
- Oral doxycycline 20 or 50 mg twice a day for 1 to 2 months. Advise patients to take the second pill at least 3 hours before going to bed. Doxycycline should not be used at all by women of child bearing age (if there is any potential for pregnancy), women who are nursing, or children. Make sure to educate all patients on doxycycline about the increased potential for sunburn and potential interaction with dairy products and antacids. When improvement is seen, the medication can be reduced to once a day for an additional month.
- Clinicians may want to consider the Alodox™ Kit for fair skinned individuals, those with stomach problems, or those who want the convenience of an all in one blepharitis kit. The kit contains low-dose (20 mg) doxycycline plus pre-moistened cleansing pads, a foam cleanser, and TranquilEyes moist heat goggles.
- Omega-3 fatty acid supplements are effective for all patients with lid disease problems. They are most appropriately used as part of a long-term management strategy.
- If lid disease is still present after several months of treatment, rule out lid laxity, ectropian, entropian, and more serious conditions such as basal cell or squamous cell carcinoma, which will often show madarosis as well.
- Warm compresses for a minimum of 5 minutes. (It is not necessary to use lids scrubs or cleansers unless concurrent anterior blepharitis is present.) Follow the compresses with lid massage/meibomian gland expression.
- Apply topical ophthalmic azithromycin (AzaSite) daily for 2 to 4 weeks or Zylet® (tobramycin and loteprednol 0.5%) four times a day for 1 week followed by an additional 2 weeks of twice-daily application. Teach patients how to use AzaSite bottle, making sure to get the medication on the eye and then gently rubbing the closed eyelids. I also advise patients to store the bottle on its side and turn it upside down and wait 3 seconds immediately before use. Another option is topical Zylet (Tobramycin 0.3% plus Loteprednol 0.5%) as the loteprednol is very lipophilic. The dosing schedule would be four times a day for 2 weeks followed by twice a day for an additional week.
- Oral doxycycline 20 mg twice a day (but note that generic 50-mg doxycycline is often the least expensive option for patients with financial concerns). If patients require lid scrubs, hot compresses, and 20mg doxycycline, the Alodox kit may be an affordable approach.
- Omega-3 fatty acid supplements are slow acting but are useful as a long-term adjunct or follow-up to hot compresses and topical medication.
- One of the best artificial tears (and the one that my lid margin disease patients prefer most of the time) is Soothe® XP. The drops can be used as needed to restore comfort and rebuild the tear film during and after medical treatment as the main ingredient is mineral oil and the typical blepharitis patient often manifests oil-deficient tears.