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    Treating blepharitis in the pediatric population

    How treating the condition in children differs from that of adults

     

    Topical antibiotic therapy

    Topical antibiotics are the next step and are particularly useful for anterior blepharitis caused by Staphylococcal infection.

    A good option for the pediatric population is ophthalmic erythromycin ointment applied one to two times a day for two weeks and discontinued after the condition has improved. Ointments offer the advantage of staying on the lid margin for a longer period of time than solutions. They do blur vision, however, so applying the ointment late in the day or at bedtime will improve tolerance.

    Topical azithromycin is dosed 1% bid x 1 week OU, then changed to 1x/day x 2 weeks.13 Azithromycin is a popular choice because it decreases the Staphylococcus found on the lid and targets meibomian gland dysfunction by improving immunomodulatory response.8 Topical azithromycin 1% has a good safety profile and is approved for children after 1 year of age and is pregnancy category B. However, this medication is often difficult to find in pharmacies and can be quite expensive.

    For severe cases of blepharitis, the use of a topical antibiotic/steroid combination may be warranted. Close monitoring is required due to the increased risk of side effects, including infection, increased intraocular pressure, cataract formation, and in the rare case of blepharitis caused by herpes simplex virus, steroid use can worsen the condition and concurrently place the cornea at risk. Topical combinations available in ointment form include tobramycin-dexamethasone ophthalmic or neomycin/polymyxin B/dexamethasone ophthalmic.1 Long-term steroid use should be avoided.

    Related: 4 steps to beating blepharitis

    Oral antibiotic therapy

    Oral azithromycin has been shown to be a good treatment for posterior blepharitis. Azithromycin is a semisynthetic with good intracellular penetration and a long half-life that may be prescribed in children older than six months. Oral azithromycin has an anti-inflammatory effect in addition to its antibacterial actions. This makes it a good choice for more severe and/or chronic blepharitis.14

    When pediatric blepharitis becomes chronic, parents of affected patients describe a pattern of waxing and waning. The patient improves when using the topical antibiotics, but signs and symptoms are noticed when their use is discontinued.8 If untreated, the patient may develop recurrent hordeola and clogged meibomian glands with thickened secretions. When bacterial exotoxins increase and overflow to the bulbar conjunctiva and/or cornea, the patient can develop phlyctenules and lid or corneal ulceration. Significant corneal involvement requires, at the least, the addition of a topical fluoroquinolone. Besivance (besifloxacin, Bausch + Lomb) may be used in children one year or older and has been approved for bacterial conjunctivitis with dosing one drop in the affected eye(s) three times a day, four to 12 hours apart for at least seven days.

    Doctors should consider ocular acne rosacea in children who present with any combination of meibomian disease, chronic blepharitis, recurrent chalazia, and chronic symptoms of photophobia, ocular irritation, and redness. The mainstay of treatment for this condition in pediatric patients is systemic erythromycin for at least 12 months.15

    Though doxycycline and other tetracycline analogs are used in adults, their use is contraindicated in children less than eight years old.16

    Related: 5 ways to go beyond baby shampoo for lid hygiene

    Tea tree oil treatments

    In cases of pediatric blepharitis that do not respond to conventional treatments, doctors should consider demodex infestation as a potential cause. A retrospective review of recalcitrant cases of pediatric patients 2.5 to 11 years old found that over 90 percent had demodex mites.11

    Demodex mites are tiny arachnid ectoparasites that feed off body products. Two types exist on humans, Demodex folliculorum and Demodex brevis. The mites and their waste products are thought to block follicles and glands found on the lid and to arouse an inflammatory response. Hallmark findings include cylindrical dandruff cuffs around the base found around the hair follicles. Tea tree oil in the form of scrubs and ointment form has been used to treat ocular demodicosis.17

    Terpinen-4-ol has been identified as the key ingredient in tea tree oil that kills demodex mites.18 Cliradex is a product that provides terpinen-4-ol, but it lacks components of tea tree oil that compete with or are ineffective against demodex. It is available as both a foaming cleanser and in a wipe form. It is applied once daily lightly against the lid, while allowing it to air dry. The period of treatment is six to eight weeks.

    Some practitioners are performing epilation on one to two isolated lashes that are thought to be involved in order to evaluate for findings of demodex under the microscope. This may or may not be an option in the pediatric patient depending on the child’s general demeanor during an exam.

    Other future treatment regimens for study for blepharitis include the use of petroleum jelly and hypochlorous acid.

    Julie Tyler, OD, FAAO
    Dr. Tyler is a module chief of primary care at The Eye Care Institute at Davie and has been a clinical preceptor in numerous NSU clinics ...
    Rachel A. Coulter, OD, MSEd, FAAO, FCOVD
    Dr. Coulter is a professor of optometry at Nova Southeastern University where she teaches, sees patients, and performs clinical ...

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