Management of posterior blepharitis

Eyelid hygiene is the mainstay of therapy and controls symptoms and signs of posterior blepharitis if performed twice daily; see Patient information: Eyelid hygiene for posterior blepharitis for a printable patient handoutThe Royal Victorian Eye and Ear Hospital (RVEEH), 2023. Reducing screen time should be recommended for patients whose symptoms are worsened by prolonged screen time.
Figure 1. Patient information: Eyelid hygiene for posterior blepharitis.

Ayre, 2023

Printable figure

Place a warm compress (eg a face-washer or make-up pad soaked in warm water) onto the eyelids (with eyes closed). Keep the warm compress in contact with the eyelids for 2 to 5 minutes to soften the crusts.

Follow this with:

  • gentle scrubbing of the body of the eyelid with
    • sodium bicarbonate solution (1 teaspoon in 500 mL of freshly boiled and cooled water) OR
    • baby shampoo solution (5 drops in 100 mL of freshly boiled and cooled water) OR
    • commercially available eyelid solution or wipes.
  • gentle massage of the eyelid with a clean finger.

Repeat these steps twice a day.

Prepare a fresh solution each day.

If symptoms of posterior blepharitis do not improve despite an adequate period (eg 4 weeks) of eyelid hygiene, systemic antibiotic therapy is used, mainly for an anti-inflammatory effect.

For adults and children 8 years or older with posterior blepharitis not improving with eyelid hygiene, use:

doxycycline1 orally, daily for a minimum of 8 weeks doxycycline doxycycline doxycycline

adult: 100 mg, reduced to 50 mg after clinical improvement (usually after 2 to 4 weeks)

child 8 years or older and less than 26 kg: 50 mg, reduced to 25 mg after clinical improvement (usually after 2 to 4 weeks)

child 8 years or older and 26 to 35 kg: 75 mg, reduced to 50 mg after clinical improvement (usually after 2 to 4 weeks)

child 8 years or older and more than 35 kg: 100 mg, reduced to 50 mg after clinical improvement (usually after 2 to 4 weeks).

For pregnant or breastfeeding people with posterior blepharitis not improving with eyelid hygiene, use:

1erythromycin (base) 500 mg orally, daily for a minimum of 8 weeks. If this dose is not tolerated, reduce to 250 mg daily. For dosage adjustment in adults with kidney impairment, see erythromycin dosage adjustment erythromycin erythromycin erythromycin

OR

1erythromycin (ethyl succinate) 800 mg orally, daily for a minimum of 8 weeks. If this dose is not tolerated, reduce to 400 mg daily. For dosage adjustment in adults with kidney impairment, see erythromycin dosage adjustment. erythromycin (ethyl succinate formulation) erythromycin erythromycin

For posterior blepharitis not improving with eyelid hygiene in children younger than 8 years or those who cannot take doxycycline, use:

erythromycin (ethyl succinate) (child 1 month or older) 20 mg/kg up to 800 mg orally, daily as a single dose, or in 2 divided doses to improve tolerability, for a minimum of 8 weeks. If this dose is not tolerated, reduce to 10 mg/kg up to 400 mg daily. erythromycin (ethyl succinate formulation)

Review after 8 weeks – maintenance therapy may be required to control symptoms.

Although uncommon, ocular rosacea can occur in children with posterior blepharitis. Unlike in adults, cutaneous symptoms of rosacea are often absent in children – seek expert advice from an ophthalmologist for posterior blepharitis that is recurrent or not resolving because corneal complications can occur even in the absence of acute symptoms.

1 Doxycycline use is limited in children because an oral liquid formulation is not marketed in Australia but is available via the Special Access Scheme. For formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return