1.2 Blepharitis, Anterior and Posterior

eyes.nhs.scot/
Eyecare Guidelines/
Section 1 - Eyelids/
1.2 Blepharitis, Anterior and Posterior

Date of last review:

19/12/2025

Date of next review:

19/12/2027

Date of publication:

19/1/2026

This is a GOS Specialist Supplementary condition and should be managed by community optometrists in line with national guidance⁽⁸⁾. This guideline should be read in conjunction with ‘Supporting information’ guidance [link to Supporting Information page]

Differential diagnosis ⁽¹⁾

Allergy
Dermatoconjunctivitis medicamentosa
Eyelid dermatitis
Parasitic infestation (e.g., Phthirus pubis)
Preseptal cellulitis
Herpes (Simplex or Zoster)
Meibomian gland carcinoma (usually unilateral)

Possible management by optometrist

Advice ⁽¹⁾

Treat coexisting Dry Eye Disease.
Explain chronic nature and need for ongoing treatment.
Lid hygiene (cleansing and vertical massage) is first-line management.
Warm compresses:
- Wet compresses loosen crusts in anterior blepharitis.
- Dry compresses melt meibum in posterior blepharitis (40°C for ≥5 min).
IPL therapy for MGD lacks strong evidence (Cochrane 2020).
Avoid cosmetics during flare-ups.
Complete eradication may not be possible; compliance reduces symptoms and relapses.

Treatment ⁽¹⁾

Lid hygiene and compress treatment as described in Advice
Topical antibiotics for staphylococcal/seborrhoeic blepharitis if hygiene fails:
- Chloramphenicol ointment twice daily
- Short course of topical azithromycin (off-label)⁽¹⁾

In patients with posterior blepharitis, systemic antibiotics may be effective as a second line treatment.

Posterior blepharitis:

Systemic antibiotics (e.g. doxycycline)
Alternatives: where tetracyclines are contraindicated, consider prescribing oral

erythromycin
- NB Evidence for oral antibiotics is limited (Cochrane 2021).
Severe symptoms: short-term mild topical steroids (e.g. FML eye drops)

Demodex blepharitis:

Lid cleaning with tea tree oil or wipes containing 4-terpineol (lower concentrations recommended).

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Chloramphenicol 1% eye ointment ^(1,5) (POM generic): Apply 3–4 times daily. The course of treatment should be 5 days (even if symptoms improve) ^(2,3)(Consult local guidance as they may vary on timescales ⁽⁷⁾)
Azithromycin 15mg/g eye drops ^(1,4) (POM generic): One drop twice daily, morning and evening, for 3 days. It is usually unnecessary to prolong treatment beyond three days ^(2,3,7)
Oral Doxycycline tablets/capsules ^(1,5) (POM): 100mg daily for 2–3 months ⁽⁶⁾
Oral Erythromycin tablets ^(1,5) (POM): 500mg twice daily for 2-3 months ^(2.3,6)
Fluorometholone (FML) 0.1% eye drops ^(1,5) (POM): One drop ⁽⁷⁾, two to four times daily. For more serious conditions apply every 1 hour for 24-48 hours, then reduce to two to four times daily ^(2,3). Duration will depend on severity of the condition ⁽⁶⁾.

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and local/national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Normally no referral ⁽¹⁾. GOS Specialist Supplementary Stage 1 where appropriate* ⁽⁸⁾
If required, GOS Specialist Supplementary stage 2* treatment should be provided by a local IP optometrist/OMP who is registered and qualified to carry out GOS Specialist Supplementary Stage 2 management; intra-referral (practice to practice) should take place to facilitate this ⁽⁸⁾
Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate (outwith GOS Specialist Supplementary) ⁽⁷⁾
Consider carcinoma or immune-mediated disease if non-responsive, especially with lash loss or cicatricial changes ⁽¹⁾
Urgent referral if meibomian gland carcinoma suspected ⁽¹⁾

*Treatment should be provided in line with “Annex C of the Statement” ⁽⁸⁾

https://www.eyes.nhs.scot/for-professionals/legislation/

Possible management in secondary care or local/community pathways where available ^(1,8)

See Further management options
Microbiological investigations (culture and sensitivity)
Active management before ocular surgery to reduce infection risk

College of Optometrists Clinical Management Guideline⁽¹⁾

Blepharitis (lid margin disease) - College of Optometrists*

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

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Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines are made available on the basis of excluding all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Eyecare Guidelines.

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Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

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