Treatment Plan

Managing Anterior Blepharitis

BY WILLIAM L. MILLER, OD, MS, PHD, FAAO

One survey indicated that between 37% to 47% of patients show signs of general blepharitis (Lemp and Nichols, 2009). Most of us see multiple blepharitis cases weekly and use a variety of treatment modalities to address this chronic condition. Anterior blepharitis has traditionally been classified as either staphylococcal or seborrheic. An additional cause may be the result of Demodex.

Patients will typically complain of itching along the eyelid margin and dry eye. Depending on the severity, they may also report red eyes and mattering upon awakening. Recognizable signs of staphylococcal anterior blepharitis include flakes/scales, collarettes, scurf, madarosis, eyelash misdirection, and hyperemic eyelid margins. You may also observe conjunctival injection, superficial punctate staining, corneal infiltrates/scarring, corneal neovascularization, and phlyctenules.

The seborrheic form may manifest as oily or greasy eyelid deposits along with seborrheic dermatitis. Often, this form of anterior blepharitis does not affect eyelash positioning.

Treatment Options

Address mild-to-moderate cases conservatively, moving to more aggressive treatments when recalcitrant or more severe. Standard first-line management is lid hygiene, which would include warm compresses and eyelid scrubs. This can be done using “home” therapies, such as a warm washcloth and baby shampoo. This may work for some, but prescribing commercially available eyelid scrubs works well for many more of my patients. Eyelid scrubs have improved since the time Key (1996) described their use. Although more costly compared to the washcloth approach, convenience and accessibility make this a great option. In addition to the manufacturers’ instructions, have your own instructions to hand to patients or provide them on your website.

A more recent addition to treatment and management is BlephEx, an in-office lid scrub device that aims to remove bacterial biofilm and clean the lid margin. The hand-held device uses a micro-sponge in conjunction with LidHygenix foam to gently remove eyelash debris. The procedure can be repeated quarterly or biannually.

In moderate-to-severe cases of anterior blepharitis, treatment strategies such as topical antibiotics and steroids can decrease the problem to be manageable with eyelid scrubs alone or can be used to augment eyelid scrubs as a chronic management strategy.

Typically, erythromycin or bacitracin ointment is applied to the lids q.d., b.i.d., or q.h.s. for at least 10 days. The anticipated outcome is a reduction in bacterial flora, which in turn decreases the severity of the anterior blepharitis so that maintenance treatment with eyelid scrubs is more effective. Oral antibiotics are more often used for meibomian gland disease rather than anterior blepharitis. Topical azithromycin has also been used to treat both anterior and posterior blepharitis. A study by Fadullah et al (2012) demonstrated an improvement in signs and symptoms after three months of treatment with topical azithromycin. The study also allowed the subjects to continue with warm compresses and eyelid scrubs while adding the topical azithromycin. Azithromycin can act by reducing staphylococcal biofilms (Wu et al, 2010).

Topical fluoroquinolones also may be used and may be more effective compared to aminoglycosides at reducing the bacterial load (John, 2012). In severe cases with severe inflammation, a short course of a topical steroid or antibiotic/steroid may be indicated to achieve clinical success.

The evolution of management strategies for anterior blepharitis over the last decade has given us more tools to address this chronic problem in our patients. CLS

For references, please visit www.clspectrum.com/references and click on document #232.

Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a consultant or advisor to Alcon and Oasis Medical and has received research funding from CooperVision, Contamac, and SynergEyes and lecture or authorship honoraria from Alcon. You can reach him at wmiller@uh.edu.