• Advise the person that good eyelid hygiene is the mainstay of treatment and should be carried out twice daily initially, then reduced to once daily. The eyelids should be cleaned in a stepwise manner:
• Apply warm compresses to the closed eyelids for 5–10 minutes.
• For posterior blepharitis, massage the eyelid to express Meibomian glands.
• Clean the eyelids thoroughly using a clean cloth or cotton bud rubbed along the lid margins, typically using baby shampoo diluted 1:10 with warm water.
• Advise women that eye make-up, especially eyeliner, may contribute to blepharitis. If use of eyeliner cannot be avoided, advise the person to consider one that washes off easily.
• Blepharitis frequently causes dry eye. Prescribe artificial tears or ocular lubricants to relieve symptoms.
• Consider prescribing topical antibiotics (chloramphenicol or fusidic acid) or an oral antibiotic (tetracyclines) if there are clear signs of staphylococcal infection or Meibomian gland dysfunction, respectively:
• Antibiotics should usually be reserved for second-line use when eyelid hygiene alone has proved ineffective.
• Treat for 4–6 weeks.

Eyelid hygiene:

• Warm compresses (cloths warmed with hot water) are applied to the closed eyelids for 5–10 minutes. This loosens collarettes and crusts found in anterior blepharitis and warms Meibomian secretions, reducing viscosity:
• An alternative to using a cloth as a warm compress is to use a commercial product specifically designed for this purpose, such as EyeBag^®, which may be more convenient.
• EyeBag^®, as well as commercially available eyelid scrubs used for cleaning, are available over-the-counter but are not available on FP10 forms.
• To massage the eyelid, gently rub the eyelid margin with a circular motion. This compresses the Meibomian glands and expresses their contents. This stage can be omitted if anterior blepharitis alone is present.
• A variety of cleansers can be used to clean the eyelid and margins; these include baby shampoo (diluted 1:10 with warm water; probably the most commonly used cleanser), sodium bicarbonate (one teaspoonful dissolved in a cup of boiled water), and commercial eyelid scrubs. Encourage the person to find which formulation is most suitable for them.

Dry eyes:

• A range of products is available to relieve symptoms of dry eye. For a complete list and for information on application and adverse effects, see Artificial tears and ocular lubricants in Prescribing information:
• Tear replacement products include hypromellose, carbomers, polyvinyl chloride, sodium chloride, carmellose sodium, hydroxyethylcellulose, and povidone. All are available without preservatives.
• Ocular lubricants (e.g. paraffins) cause blurring of vision and are not suitable for use with contact lenses, but may be helpful at night.
• For further information on the management of dry eye, see the CKS topic on Dry eye syndrome.

These recommendations are largely based on expert opinion, as only weak evidence from a few small clinical trials is available. CKS did not identify any UK guidelines on the management of blepharitis, but these recommendations are consistent with US guidelines on blepharitis [American Optometric Association, 2002; American Academy of Ophthalmology, 2003] and with expert reviews of good clinical practice [Denton et al, 1999; Pray and Pray, 2002].

Eyelid hygiene:

• Definitive treatment recommendations regarding eyelid hygiene in blepharitis cannot be made because evidence from clinical trials is limited:
• Baby shampoo is probably the most widely used product for cleansing eyelids. Other products, such as sodium bicarbonate or soap, can be used, but they may be more likely to irritate the eyelid. The optimal dilution factor of baby shampoo with water is unknown, but 1:10 is often recommended as providing a good balance between irritating and cleaning actions [Denton et al, 1999].
• Because eye make-up can aggravate blepharitis, experts recommend that it be avoided.
• Some experts recommend use of anti-dandruff shampoos on the scalp and eyebrows, particularly if seborrhoeic dermatitis is also present [American Optometric Association, 2003].

Ocular lubricants:

• Blepharitis, particularly posterior blepharitis (Meibomian blepharitis), is often associated with a poor-quality tear film and dry eye syndrome. Artificial tears and ocular lubricants (eye ointments) are used to relieve symptoms and prevent deterioration of the cornea [DEWS, 2007].

Topical and oral antibiotics:

• Recommendations on the use of topical and oral antibiotics are largely based on expert opinion, as only weak evidence from a few small clinical trials is available [American Academy of Ophthalmology, 2003].