Guideline sources The following summarized guidelines for the evaluation and management of blepharitis are prepared by our editorial team based on guidelines from the College of Optometrists (CO 2023), the American Academy of Ophthalmology (AAO 2022; 2019), and the British Association of Dermatologists (BAD 2021). 1 2 3 4 Guidelines 1. Screening and diagnosis Differential diagnosis: As per AAO 2022 guidelines: Suspect an eyelid tumor in patients with atypical eyelid margin inflammation or disease not responding to medical treatment and obtain a careful re-evaluation in these patients. https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 1/6 6/29/23, 3:18 AM Blepharitis Pathway Refer patients with an inflammatory eyelid lesion appearing suspicious for malignancy to an appropriate specialist. As per AAO 2019 guidelines: Consider distinguishing blepharitis and meibomian gland dysfunction from aqueous deficient dry eye in patients with ocular surface disease. Recognize that worsening of symptoms in the morning is typical of blepharitis, whereas worsening of the symptoms later in the day is typical of aqueous deficient dry eye. E Suspect carcinoma or immune-mediated diseases in patients with blepharitis not responding to therapy, particularly if the blepharitis is associated with a loss of eyelashes and/or conjunctival cicatricial changes. Ensure early diagnosis and appropriate treatment to prevent disfigurement. E 2. Diagnostic investigations History and physical examination: Elicit initial history, including the following: Situation Guidance Redness, irritation, burning, tearing, itching, crusting of eyelashes, loss of eyelashes, eyelid sticking, blurring or fluctuating vision, contact lens intolerance, photophobia, increased frequency of blinking, and recurrent hordeolum Ocular symptoms and signs Time of day when symptoms are worse, duration of symptoms Chronology of symptoms Unilateral versus bilateral presentation Laterality of symptoms Smoke, allergens, wind, contact lenses, low humidity, retinoids, diet, alcohol consumption, and eye makeup Exacerbating conditions Rosacea, atopy, psoriasis, and GvHD Symptoms related to systemic diseases Antihistamines or drugs with anticholinergic effects, or drugs used in the past that might have an effect on the ocular surface, such as isotretinoin Current and previous systemic and topical medications Patient with pediculosis palpebrarum Recent exposure to an infected individual Previous intraocular and eyelid surgery, local trauma, including mechanical, thermal, chemical, and radiation injury, history of Ocular history https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 2/6 6/29/23, 3:18 AM Blepharitis Pathway cosmetic blepharoplasty, history of styes and/or chalazia. Perform initial physical examination, including assessment of visual acuity, external examination of the skin and eyelids, and slit-lamp biomicroscopy (including tear film, anterior eyelid margin, eyelashes, posterior eyelid margin, tarsal conjunctiva, bulbar conjunctiva, and cornea). Conjunctival culture: consider obtaining cultures in patients with recurrent anterior blepharitis with severe inflammation as well as in patients not responding to treatment. 3. Diagnostic procedures Eyelid biopsy: consider performing an eyelid biopsy to exclude the possibility of carcinoma in patients with marked asymmetry, resistance to treatment, or unifocal recurrent chalazia not responding well to treatment. Consult a pathologist before performing the biopsy if sebaceous cell carcinoma is suspected. 4. Medical management Topical antibiotics: As per CO 2023 guidelines, consider offering topical antibiotics in patients with staphylococcal or seborrhoeic blepharitis not controlled by first-line management: antibiotic ointment (such as chloramphenicol) BID; place in eyes or rub into lid margin with fingertip short course of topical azithromycin (off-label use). C As per AAO 2022 guidelines, consider offering topical antibiotics, such as bacitracin or erythromycin, applied 1 times daily or at bedtime on the eyelid margins for a few weeks. As per AAO 2019 guidelines, consider offering topical antibiotic ointments, with or without corticosteroids or oral antibiotics, in patients with blepharitis. E Topical corticosteroids: Consider offering a short course of topical corticosteroids at the minimal effective dose for eyelid or ocular surface inflammation, such as severe conjunctival infection, marginal keratitis, or phlyctenules. Avoid using corticosteroid therapy for long term if possible. Re-evaluate patients receiving corticosteroids within a few weeks of initiation to determine the response to treatment, measure intraocular pressure, and assess treatment compliance. Oral antibiotics: As per CO 2023 guidelines: Consider offering systemic antibiotics (such as doxycycline or minocycline for several weeks or months; or oral erythromycin or azithromycin if tetracyclines are contraindicated) as second- line therapy in patients with posterior blepharitis. C https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 3/6 6/29/23, 3:18 AM Blepharitis Pathway Insufficient evidence to support the use of oral antibiotics in patients with chronic blepharitis. I As per AAO 2022 guidelines, consider offering oral tetracyclines with topical antibiotics in patients with meibomian gland dysfunction with chronic symptoms and signs not adequately controlled with eyelid cleansing or meibomian gland expression. 5. Nonpharmacologic interventions Eyelid cleansing: As per CO 2023 guidelines, advise eyelid cleansing measures to wipe away bacteria and deposits from eyelid margins and to improve signs and symptoms in patients with blepharitis. B As per AAO 2022 guidelines, advise eyelid cleansing and eyelid hygiene for the initial management of patients with blepharitis. Warm compresses: As per CO 2023 guidelines, advise wet warm compresses to loosen collarettes and crusts in patients with anterior blepharitis. Apply dry, warm compresses to the lid skin BID for 5 minutes at 40 C to melt meibum in patients with posterior blepharitis. B As per AAO 2022 guidelines, advise warm compresses for the initial management of patients with blepharitis. 6. Therapeutic procedures Intense pulsed light therapy: insufficient evidence to recommend intense pulsed light therapy for the management of meibomian gland dysfunction. I 7. Specific circumstances Patients with Demodex blepharitis: Suspect Demodex blepharitis in patients with characteristic cylindrical dandruff at the roots of eyelashes or refractory blepharitis. B Insufficient evidence to support the use of tea tree oil in patients with Demodex blepharitis. Use lower concentrations to avoid ocular toxicity when using tea tree oil. I Patients with rosacea (pharmacotherapy): offer topical azelaic acid, topical ivermectin, topical brimonidine, oral doxycycline, or oral isotretinoin for blepharitis in patients with rosacea. B Patients with rosacea (nonpharmacologic management): advise minimizing exposure to aggravating factors (such as air conditioning, excessive central heating, smoky atmospheres, and periocular cosmetics) in patients with ocular rosacea. A Show 4 more https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 4/6 6/29/23, 3:18 AM Blepharitis Pathway Patients with rosacea (indications for referral): Refer patients with ocular rosacea to an ophthalmologist in case of: eye discomfort, sticky eye discharge persisting > 12 months despite frequent (> 6 times daily) topical lubricant use and adequate lid hygiene symptoms keeping the patient awake at night (such as reduced vision, pain on eye movement, and pain). A 8. Patient education General counseling: As per AAO 2022 guidelines, counsel patients about the chronicity and recurrence of the disease process and that symptoms can frequently be improved but are rarely eliminated. As per AAO 2019 guidelines, educate patients that blepharitis is typically a chronic condition that cannot be permanently cured, and successful management is dependent on patient compliance with a treatment regimen. E 9. Follow-up and surveillance Follow-up: arrange follow-up visits to elicit interval history, measure visual acuity, perform external physical examinations, and obtain slit-lamp biomicroscopy. Clinical findings Symptoms Past medical history Dry eyes Chalazion Eye discharge Dry eye disease Eye pain Giant papillary conjunctivitis Foreign body sensation in the eyes IBS Pterygium Gritty eyes Rosacea Itchy eyes Ulcerative colitis Photophobia Ocular exam Puffy eyelids Red eyes Collarettes Watery eyes Conjunctival injection Cylindrical dandruff at the roots of eyelashes Social history Tobacco use Eyelid swelling Use of contact lenses Madarosis Trichiasis https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 5/6 6/29/23, 3:18 AM Blepharitis Pathway References 1. AAO PPP Cornea/External Disease Panel, Hoskins Center for Quality Eye Care. Cornea/External Disease Summary Benchmarks 2022. AAO. 2022 Dec. Open 2. College of Optometrists. Blepharitis Lid Margin Disease). COP. 2022 Jul;v.17. Open 3. Guillermo Amescua, Esen K Akpek, Marjan Farid et al. Blepharitis Preferred Practice Pattern . Ophthalmology. 2019 Jan;126 1 P56 P93. Open 4. P J Hampton, J Berth-Jones, C E Duarte Williamson et al. British Association of Dermatologists guidelines for the management of people with rosacea 2021. Br J Dermatol. 2021 May 15. Open 5. Mary Eberhardt, Guhan Rammohan. Blepharitis. In: StatPearls Internet]. Treasure Island FL StatPearls Publishing; 2021 Jan. 2020 Jul 17. Open 6. Taliana Freitas Bernardes, Adriana Alvim Bonfioli. Blepharitis. Semin Ophthalmol. 2010 May;25 3 79 83. Open 7. Guillermo Amescua, Esen K Akpek, Marjan Farid et al. Blepharitis Preferred Practice Pattern . Ophthalmology. 2019 Jan;126 1 P56 P93. Open 8. College of Optometrists. Keratitis (marginal). COP. 2022 Jan;v.12. Open https://web.pathway.md/diseases/rec6OLM39Q041Xaqa 6/6