Blepharitis is a prevalent disorder with many recognized therapeutic options. Hygienic regimens, topical agents and even oral medications are used in management. But, how many of us truly understand the role of each therapeutic measure, or use them appropriately and effectively? Many prac- titioners have pre-printed education sheets for blepharitis, that describe the process of lid soaks and/or lid scrubs in detail. Unfortunately, simply distributing literature to patients does not ensure appropriate management. More importantly, not every case of blepharitis responds favorably to simple lid hygiene. Successful therapy must be tailored to each individual patient.

Seborrheic Blepharitis
Seborrhea represents an inflammatory dermatologic condition and does not result from an infectious process. Warm compresses applied b.i.d. to q.i.d. help melt away the waxy scales associated with seborrhea. Likewise, lid scrubs using a very dilute detergent-based solution (e.g., Johnsons Baby Shampoo or Neutrogena soap) can help remove the excess sebum. Commercially available eyelid cleansing pads may provide a more convenient, if more costly, means of achieving this outcome.¹

Seborrhea has been associated with a pathogenic yeast (Pityrosporum ovale, also known as Malas-sezia furfur). Shampoos contain- ing antifungal agents, such as zinc pyrithione and selenium sulfide are available. However, these shampoos are not indicated for use in or around the eye. Topical steroid preparations are likewise discouraged. Although steroids may provide short-term relief, they tend to hasten recurrences and foster dependence. Moreover, the potential ocular risks associated with long-term topical steroid use are a significant deterrent.

Advise patients with associated seborrheic dermatitis to seek dermatologic consultation, as alleviating the underlying condition may further help with blepharitis management. In addition to special shampoos, topical ketoconazole 2% cream and oral itraconazole may treat more resistant cases. However, both have been studied in the treatment of seborrheic blepharitis with mixed results.^2-4

Meibomian Gland Dysfunction (MGD)
MGD is a multifactorial disorder, but infection is not a major cause. While enhanced bacterial growth is associated with MGD, it is a secondary phenomenon that occurs deep within the glands, outside the reach of most topical agents. Some practitioners still recommend topical antibiosis for MGD, but in our experience, this is not terribly efficacious. Lid hygiene plays a much more significant role in the initial and ongoing management. Warm compresses combined with vigorous lid massage soften the thickened secretions within the meibomian ducts and stimulate normal sebaceous flow from these glands.

Lid scrubs, though, are not as useful. One study showed that MGD actually results in saponificationthat is, the creation of detergentwithin the tear film, due to the enhanced formation of free fatty acids and inflammation.⁵ The addition of more detergent to an already unstable ocular surface only compromises the tear film further and may contribute to poor patient compliance.^1,5 Therefore, it is probably best to refrain from lid scrub therapy when managing MGD.

Oral tetracycline and its derivatives (e.g., doxycycline and minocycline) are important to consider in more recalcitrant cases. Tetracycline appears to inhibit bacterial lipase production and reduce free fatty acids, which accounts for its great efficacy in MGD management. This is particularly true for those patients who have ocular rosacea.⁶ In addition, a recent study showed that tetracyclines have anti-inflammatory properties and specifically inhibit matrix metalloproteinase-9 and interleukin-1, both powerful modulators of inflammation.⁷ While we may not fully comprehend how these drugs work, a regimen of oral doxycycline 100mg b.i.d. x 4 weeks, then q.d. x 4-8 weeks, is often very effective in MGD management.⁸

Another potential treatment option for MGD is the nutraceutical route. Proponents of this ther- apy maintain that meibomian secretions are derived from omega-3 essential fatty acids, which can only be obtained through dietary intake. A recent report suggests that flax- seed oil may help to produce clearer and thinner meibomian secretions in patients who have evaporative dry eye.⁹ Other studies have shown that systemic administration of essential fatty acids diminishes the inflammation and symptomology associated with MGD and dry eye.¹⁰ More prospective clinical trials are necessary to determine if nutraceuticals represent a legitimate treatment option for MGD, but the anecdotal evidence is compelling.

Finally, Restasis (cyclosporine, Allergan) may also have a beneficial effect in patients who have MGD. A recent report suggests that topical cyclosporine diminishes meibomian gland inclusions and reduces lid margin injection in patients who have posterior blepharitis.^11,12 Other long-term controlled studies have yet to corroborate these reports, but this may prove to be an added advantage for those dry eye syndrome patients who use Restasis.

While there are numerous beneficial therapies for blepharitis, practitioners must remain wary of adop- ting a one-size-fits-all attitude in the management of this disorder. Clearly, not all these modalities are suitable for every patient, and some therapeutic choices may actually worsen the condition if applied haphazardly.

The key to management is careful differentiation, appropriate and conservative initial therapy, and vigilant follow-up to determine if the treatment is effective. n