OSN discussion on blepharitis treatments

Ocular Surgery News ran an interesting discussion amongst seveal ophthalmologists about treatments for blepharitis. In some cases the differences in views about what treatments to start with is quite striking.

Physicians examine treatment options for patient with blepharitis

COMPRESSES
I was pleased to see general agreement about the importance of warm compresses... but I wonder how much attention any of them are paying to methods and ensuring their patients get compresses that are conducive to compliance.

PLUGS
The usual "cesspool" talk about premature insertion of plugs when there is active blepharitis.

ORAL ANTIBIOTICS
There was some discussion about longterm use of doxy etc. Dr. Slonim compares doxycycline, minocycline and tetracycline. Clearly the frequency with which these antibiotics are prescribed has decreased since the study came out linking them to increased breast cancer risk in women, though Dr. MacDonald (whose regimen sounded like the most Rx-heavy amongst them incidentally) points out:

That study revealed an apparent relationship between oral antibiotic use and breast cancer in women; the results initially panicked everyone. You have to tell patients in advance that the one exception was the group of women on macrolide and tetracycline antibiotics for skin and dermatological/external disease conditions — there was no correlation. So you have to point that out to them in advance because your patients will find the study, and they will call you the next day about it.

TOPICAL ANTIBIOTICS and STEROIDS
Quite a range of opinions, from Dr. Slonim who routinely prescribes them to Dr. Raizman, who minimizes emphasis on drugs in general because of the chronic nature of the condition... rather, his focus is on heat and omega 3s as standard treatment:

I think just about every patient should be using hot compresses. That is easy and safe. If you see terrible meibomian gland obstruction, those patients need doxycycline, minocycline or tetracycline.

Most patients are much more mild. You start to talk to them about antibiotics, and right away they are worried about taking a chronic antibiotic therapy, and justifiably so. And now we have good data to support the use of oils taken orally that are quite helpful for the mild to moderate cases of meibomian gland disease. So I’ll have patients take flax or fish oil, about 2,000 mg a day. I do not think it is critical to focus on one particular type of oil. I think patients get benefits from using any of these products, but that would be my second line of treatment.

I like to avoid steroids. This is a chronic disease. Yes, you can clear them up temporarily. None of us want our patients on steroids for blepharitis for months or years, so I will use them for an occasional flare-up, but I like to stay away from that.

I do not find Restasis to be especially helpful. Occasionally, some patients will get benefit from it, but that is definitely low on my list of treatments, as are topical antibiotics to the lid margins. I do not find that to be as effective, either. So using that combination of strategies, more or less in that order, I get good results on the majority of my patients.