Management of Persistent Eye Crusting in an Adolescent

Initial Treatment Approach

The American Academy of Ophthalmology recommends applying warm compresses to the eyelids for several minutes using hot tap water on a clean washcloth, an over-the-counter heat pack, or a homemade bean/rice bag heated in the microwave to soften adherent crusts and scales 1
The patient should be instructed to avoid compresses that are so hot they burn the skin, and perform eyelid cleansing after warm compresses by gently rubbing the base of the eyelashes using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip 1
Eye cleaners with hypochlorous acid at 0.01% have strong antimicrobial effects and can be used for anterior blepharitis, and the eyelid margins should be rubbed from side to side to remove crusting from the eyelashes 1

Topical antibiotic ointment such as bacitracin or erythromycin should be applied to the eyelid margins one or more times daily, as topical antibiotics have been shown to provide symptomatic relief and decrease bacteria from the eyelid margin in cases of anterior blepharitis 1

Once- or twice-daily compresses and massage at a time most convenient for the patient is generally adequate, and a schedule of regularly performed eyelid cleansing, daily or several times weekly, often blunts the symptoms of chronic blepharitis 1
Patients should be advised that warm compress and eyelid cleansing treatment may be required long term, because symptoms often recur when treatment is discontinued 1

The patient must understand that a cure is usually not possible, and the optimal treatment regimen often requires persistence and a trial-and-error approach 1
Patients who lack manual dexterity or necessary skill should be counseled carefully, as cleaning the eyelid using these devices and/or digital massage can potentially be dangerous, and frequent manipulation of the eyelid may lead to mechanically induced irritation 1

If symptoms persist despite eyelid hygiene and topical antibiotics, consider adding topical anti-inflammatory agents such as corticosteroids or cyclosporine, although evidence on the effectiveness of topical corticosteroids or oral antibiotics for blepharitis has been shown to be inconclusive 1
Long-term antibiotic treatment may result in the development of resistant organisms, so this should be considered when planning extended therapy 1

Aggressive pressure on the lids should be avoided in patients with advanced glaucoma or history of glaucoma filtering procedures, as this may subsequently increase eye pressure, and proper counseling of patients with neurotrophic corneas is important to avoid injury to corneal epithelium during eyelid cleansing 1