• Assess the severity and impact of blepharitis, previous treatments and response, type of blepharitis, presence of associated conditions, and the presence of complications.
• Provide information about the course of the disorder and emphasize the importance of complying with treatment, especially eyelid hygiene.
• Treat according to the type of blepharitis (if known) and the severity of the condition.
• Eyelid hygiene is the mainstay of treatment regardless of the cause and needs to be continued indefinitely.
• Blepharitis is commonly associated with dry eyes. Consider symptomatic treatment with artificial tears and ocular lubricants (see the CKS topic on Dry eye syndrome).
• Topical or oral antibiotics may occasionally be needed at initial presentation.
• If initial treatment is inadequate, consider prescribing an antibiotic second-line:
• Use topical chloramphenicol ointment if staphylococcal infection is considered to be a factor in poor response. Topical fusidic acid is an alternative.
• Use an oral tetracycline (tetracycline, oxytetracycline, lymecycline, or doxycycline) if Meibomian gland dysfunction is suspected.
• Refer if the condition fails to improve after maximal treatment in primary care, or if the person has:
• Sudden onset of visual loss, or an eye becomes acutely painful and red — provide same-day referral.
• Signs and symptoms consistent with cancer.
• Gradually deteriorating vision or other evidence of corneal disease.
• Associated disease that needs treatment (e.g. Sjögren's syndrome or eyelid deformities).
• Uncertain diagnosis.

• If there is rapid onset of visual loss or an acutely painful red eye, refer for same-day evaluation — see Referral criteria.
• Assess:
• The severity of blepharitis and its impact on the person.
• Severity of discomfort correlates poorly with objective clinical signs. Some people have severe symptoms but mild clinical signs; and some people have mild symptoms but severe clinical signs.
• The type of blepharitis — see Diagnosis.
• Previous treatments and response.
• For dry eyes and other complications of blepharitis, see Complications.
• For associated conditions that might also need managing see the CKS topics on:
• Seborrhoeic dermatitis.
• Rosacea.

• These recommendations are pragmatic advice based on the pathology, complications, associated disorders, and differential diagnoses of blepharitis [American Academy of Ophthalmology, 2003; Miller et al, 2005].

• Give information about the course of the illness. Explain that:
• Blepharitis is a chronic or intermittent condition, and although it cannot typically be cured permanently, symptoms can usually be controlled with adequate self-care measures.
• Compliance with treatment, especially eyelid hygiene, is essential, and eyelid hygiene should be continued even when the condition is well controlled.
• Complications, such as eyesight loss, are rare, especially when treatment is adhered to.

• Written information can be given about the nature of the disorder and to reinforce the need to adhere to treatment, especially the continued use of eyelid hygiene. For people who have internet access, www.goodhope.org.uk is a useful resource from the NHS on eyelid hygiene and other aspects of blepharitis.
• It may help for people to consider eyelid hygiene as just another daily activity, such as brushing teeth or showering [Pray and Pray, 2002].
• For information on first-line treatments, including eyelid hygiene, see Treatment at initial presentation.

• These recommendations are based on consensus opinion and reflect good clinical practice. CKS did not identify any UK guidelines on the management of blepharitis, but these recommendations are consistent with US guidelines on blepharitis and associated disorders [American Optometric Association, 2002; American Academy of Ophthalmology, 2003]:
• Helping people understand the chronic nature of the condition and the continuing need for treatment, particularly the practice of good eyelid hygiene (even when blepharitis is well controlled), may improve compliance.

• 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].

• Ask the person about eyelid hygiene. If this has been complied with, but is ineffective on its own, consider offering antibiotics (if not already tried):
• Topical antibiotics should usually be tried first, especially if there are signs of staphylococcal infection on the anterior lid margins. A 6-week trial course is usually adequate:
• Chloramphenicol eye ointment is a suitable first-line option (ointment is generally preferred to drops).
• Fusidic acid eye drops are an alternative.
• Treat for 4–6 weeks.
• Consider prescribing oral tetracyclines if topical antibiotics have failed to elicit an adequate response, or if there are signs of Meibomian gland dysfunction or rosacea:
• Low-dose tetracycline, oxytetracycline, lymecycline, or doxycycline is recommended.
• Prescribe for a minimum of 6 weeks. However, a 3-month course will usually provide a prolonged effect.
• Repeated courses are often required intermittently.

• Eyelid hygiene should be maintained throughout, as this is the mainstay of treatment.
• For information on the signs of staphylococcal infection and Meibomian gland dysfunction, see Examination.
• For further information on how antibiotics should be used and their contraindications and adverse effects, see Prescribing information:
• Topical antibiotics.
• Oral tetracyclines.

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].

Topical antibiotics:

• CKS found no relevant randomized placebo-controlled trial of a topical antibiotic for treating blepharitis. However, evidence from a small before-and-after trial and two small case series supports their use.
• Chloramphenicol is the first-line topical antibiotic of choice in the UK [BNF 54, 2007]:
• Chloramphenicol is one of the oldest antibiotics to be used in clinical practice. As such, controlled trials to support its effectiveness in the treatment of blepharitis are lacking. However, clinical experience over many years supports its use for this condition.
• Chloramphenicol is inexpensive and is well tolerated by most people. The eye ointment formulation is usually recommended, as it stays in contact with the skin and eyelid margin longer; however, eye drops may be suitable if there is coexisting conjunctivitis.
• Fusidic acid is an alternative topical antibiotic to chloramphenicol:
• Fusidic acid is only available as eye drops. It may be more suitable for people who also have corneal involvement or conjunctivitis.
• Ciprofloxacin is used extensively in the US [Bloom et al, 1994; Adenis et al, 1996]. However, it is usually reserved for second-line use in the UK because of concern about increasing resistance of bacteria to quinolones. The ointment formulation is currently undergoing post-marketing surveillance (black triangle) [BNF 54, 2007].

Topical corticosteroids, with or without antibiotics:

• Topical ocular corticosteroids (alone or combined with topical antibiotics) are not recommended for use in primary care (unless they are prescribed following specialist assessment), as they can result in severe adverse effects, including cataracts; glaucoma; and viral, bacterial, or fungal infections involving the eyelid, conjunctiva, and cornea [Watson and Coroneo, 2001; McGhee et al, 2002; BNF 54, 2007].

Oral tetracyclines:

• CKS found no relevant randomized placebo-controlled trial of an oral tetracycline for treating blepharitis, but evidence from a small before-and-after trial and a small case series supports the use of oral tetracyclines.
• The doses of tetracycline used during treatment are probably sub-therapeutic if the mechanism of action was solely that of an antibiotic. In vitro studies suggest that tetracyclines may inhibit bacterial lipases, with a subsequent reduction in free fatty acid production. Inhibition of keratinization and antimicrobial activity may also be important [Dougherty et al, 1991].
• Any tetracycline can be used, but oxytetracycline or doxycycline are probably most suitable:
• Oxytetracycline and tetracycline are inexpensive and only require twice-daily dosing. They should be avoided in people with renal dysfunction.
• Lymecycline and doxycycline only require once-daily dosing. Both can be taken with food, which may reduce gastrointestinal intolerance and improve compliance. However:
• Doxycycline should be avoided in people who are exposed to a lot of sunlight or other ultraviolet light sources.
• The dose of lymecycline cannot be tapered, unlike other tetracyclines.

• Refer for same-day ophthalmological assessment if:
• The person experiences sudden onset of visual loss, or
• An eye becomes acutely painful and red.
• Refer with urgency appropriate to the problem if:
• Cancer is suspected (squamous cell, basal cell, or sebaceous cell carcinoma of the eyelid margin):
• Persistent localized disease or resistance to treatment.
• Marked eyelid asymmetry.
• There are symptoms of corneal disease (pain, blurred vision).
• Vision deteriorates.
• The diagnosis is uncertain.
• There is associated disease, such as Sjögren's syndrome or eyelid deformities.
• There is insufficient improvement despite maximal treatment available in primary care.

• Referral is usually made to an eye specialist (e.g. ophthalmologist) for eye problems and to a dermatologist for an associated skin condition.
• In secondary care, people who have had an inadequate response to primary care management may be offered a topical ocular corticosteroid.

• These CKS recommendations are, in the absence of clinical evidence, based on what is accepted in the UK as good clinical practice.