March 2019


Tackling blepharitis in children and teenagers

by Vanessa Caceres EyeWorld Contributing Writer

Dr. Boente performs an eye examination on a 6-year-old patient at Riley Hospital
For Children.
Source: Riley Children’s Health


Underdiagnosed condition requires vigilant care

Identifying and treating blepharitis in children and teenagers can be a challenge. It often goes undiagnosed, and when it is identified, patients have trouble keeping up with the treatment regimen. However, it’s still possible to provide relief to the children and teens who have blepharitis.

How common is it?

Although there are no definitive studies that state how common blepharitis is in pediatric patients, the ophthalmologists who treat them frequently observe it.
“The prevalence of blepharitis in kids and teens is not clear, but kids and teens who have it may be asymptomatic, unable to articulate or verbalize complaints, or difficult to examine and are more likely to go undiagnosed,” said Charline Boente, MD, pediatric ophthalmologist, Riley Hospital for Children at Indiana University Health, Indianapolis.
“It is thought that the incidence is rising in the pediatric population,” said Ilyse Haberman, MD, assistant professor, Department of Ophthalmology, NYU Langone Health, New York. “Studies have indicated that it is the most common pediatric diagnosis in children who get referred to corneal subspecialists.”
At Wills Eye Hospital, Philadelphia, over a 5-year period, 15% of all pediatric patients referred in for consultation were given a diagnosis of blepharokeratoconjunctivitis, said Beeran Meghpara, MD, cornea service, Wills Eye Hospital.

Why it occurs

Just as the causes of blepharitis in adults are not always known, the causes in pediatric patients are not always clear.
“Some children with genetic syndromes commonly have blepharitis, such as Down syndrome, but otherwise it is common throughout childhood,” said Alex Levin, MD, chief, pediatric ophthalmology and ocular genetics service, Wills Eye Hospital.
“There are no definitive population studies to conclude it is more prominent in a particular gender or ethnicity,” Dr. Meghpara said. “There may be an association with rosacea or acne vulgaris.”
Blepharitis also may be seen in patients with seborrheic dermatitis, Demodex folliculorum, and giant papillary conjunctivitis, said Robert Honkanen, MD, chairman, Department of Ophthalmology, Stony Brook Medicine, Stony Brook, New York.
One cause that Dr. Boente thinks needs further exploration is digital screen time. “Many studies have correlated dry eye disease with digital screen time, but what role the meibomian glands play is still unclear, such as whether increased digital screen time can actually cause or exacerbate meibomian gland dysfunction,” she said.


With no controlled clinical trials to guide pediatric blepharitis therapy, treatments can vary by specialist.
“The mainstay of treatment in all age groups involves warm compresses to the lids and a topical antibiotic, usually erythromycin or bacitracin,” Dr. Meghpara said.
Dr. Honkanen advises applying warm, moist compresses to the child’s eyes for a few minutes several times a day and cleaning the eyelids every day with a clean, wet washcloth and a gentle baby shampoo. He also discourages eye rubbing.
Topical or oral antibiotics are often added along with the warm compresses or lid scrubs, or when the compresses/scrubs alone don’t provide enough treatment.
“Erythromycin ointment can be used in any age, or azithromycin drops can be used in children older than 1,” Dr. Haberman said. “If there is significant meibomian gland dysfunction or acne rosacea, oral azithromycin can be used in young children, or doxycycline is prescribed for children older than 8.” Doxycycline is typically avoided in younger children due to the risk of tooth discoloration and dental enamel hypoplasia, Dr. Meghpara said.
Because erythromycin requires dosing several times a day, there has been a shift at Dr. Meghpara’s office to oral azithromycin dosed once daily in children, although he said the data on this are limited.
Topical steroids also can be part of the treatment mix in refractory cases, Dr. Meghpara said. “This is done with caution and limited duration in all children and teens because of their side effects, such as high intraocular pressure, cataract formation, and risk of infection.”
Treatment of concurrent dry eye may involve preservative-free artificial tears, cyclosporine, and punctal plugs, Dr. Honkanen said. “Blepharitis can lead to dry eye, and dry eye can worsen blepharitis, so patients need to treat both,” Dr. Haberman said.
Certain procedures available for blepharitis in adults are not available or are not easily performed in children, including LipiFlow (Johnson & Johnson Vision, Santa Ana, California) and BlephEx (Franklin, Tennessee), Dr. Honkanen said.
Some ophthalmologists recommend omega-3 supplementation in pediatric patients with blepharitis, although the recent large-scale Dry Eye Assessment and Management (DREAM) study may not support this, Dr. Honkanen said.1
“In younger children diagnosed with blepharitis, it’s also important to closely assess for refractive error, corneal opacification, and amblyopia risk,” Dr. Boente said. “Sometimes an exam under anesthesia is needed in younger children to know the full extent of any disease.”

Making treatments easier

Although the treatments for blepharitis may sound straightforward enough, this is where things can get complicated for patients and parents. “In kids, the biggest challenge is getting them to sit still and comply. The help of diligent, invested parents is key,” Dr. Levin said.
Specialists shared some pearls for parents to make treatment a little easier.
• Keep them busy. “If the treatment can be coupled with something else the child is doing, like during bathing or while watching TV, that can be more successful,” Dr. Meghpara said.
• Model the treatment. “Sometimes showing them or practicing the treatments on their dolls can help mitigate their fears,” Dr. Honkanen said.
• Educate parents. “I think explaining the pathophysiology to parents in terms they can understand helps improve compliance, so they know the purpose of their efforts,” Dr. Boente said.

Recurring condition

Most of the time, blepharitis is not a one-and-done occurrence. “Usually blepharitis is a chronic, recurring problem that typically will not completely resolve. It often requires long-term treatment to control symptoms,” Dr. Honkanen said. Dr. Levin has seen cases that require treatment for months and sometimes years.
Dr. Meghpara will try to discontinue oral antibiotic therapy after about 6 months, but it sometimes needs to start again. For flare ups, he prescribes short courses of topical steroids.


1. Dry Eye Assessment and Management Study Research Group, et al. n-3 fatty acid supplementation for the treatment of dry eye disease. N Engl J Med. 2018;378:1681–1690.

Editors’ note: The physicians have no financial interests related to their comments.

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