Key messages

• It is unclear if eye drops to reduce immune responses of the eye surface, such as topical corticosteroids and cyclosporine, have any effect on the signs and symptoms of blepharitis at 4 to 12 weeks. There is limited evidence that topical corticosteroids plus antibiotics probably result in a greater reduction in corneal staining than antibiotics alone.

• More studies are needed to evaluate the long-term benefits and harms of these eye medications in a standardized manner for symptoms and signs of blepharitis.

What is blepharitis?
Blepharitis is a common condition of the eyes. It refers to swollen and itchy eyelids as a result of inflammation. Symptoms of blepharitis include a gritty sensation, soreness, itchiness and tearing, which are the most frequent complaints seen in eye clinics. There can be various causes of blepharitis, including infection, blocked oil glands, or skin conditions.

How is blepharitis treated?
Eyelid hygiene is the initial treatment for blepharitis, which includes both eyelid warming and scrubbing of the eyelids. Eyelid warming can be done with a hot towel or heat pack placed over closed eyes. In some cases, clinicians may prescribe an antibiotic eyedrop or ointment to reduce or eradicate bacteria on the eye surface. If the inflammation is severe, clinicians may prescribe medications that reduce inflammation, such as corticosteroids and steroid-sparing immunosuppressants (drugs that prevent the immune system from fighting inflammation), such as cyclosporine and tacrolimus. As blepharitis is inflammation, eye drops that reduce our immune response may have a role as a treatment. However, at present there are no clear guidelines about the indication, duration of treatment, and optimal concentration or preparation of these eye medications.

What did we want to find out?
We wanted to find out how well eye medications, that act on reducing the inflammation on the surface of the eye, can treat blepharitis.

What did we do?
We searched for studies that tested eye medications to treat blepharitis, and compared it with a different topical immunosuppressant, a different dose of the same medicine, placebo (a sham treatment that does not contain any medicine but looks the same as the medicine being tested), conventional treatment such as lid hygiene (cleansing the eyelids) or artificial tears, antibiotics, or no treatment at all. Any study that tested different medications in two eyes of a single participant was excluded.

What did we find?
We included 12 studies with a total of 2752 participants (2802 eyes) that investigated topical (applied directly to the eyes) corticosteroids with or without antibiotics, topical cyclosporine, and topical tacrolimus as immunosuppressive agents. Six of the trials were conducted in the United States. The point of assessment and duration of treatment ranged from 2 to 12 weeks.

What are the main results of our review?
The long-term effects of eye medications on symptoms and signs of blepharitis beyond 12 weeks were uncertain. We do not know if topical corticosteroids (with or without antibiotics), including cyclosporine, have an effect on composite symptom scores, compared with placebo or antibiotics alone.

No study comparing topical corticosteroids (with or without antibiotics) with placebo assessed tear breakup time (time taken for the first dry spot to appear on the eye after a blink). Topical corticosteroids plus antibiotics probably do not improve tear breakup time compared to antibiotics alone. It is unclear if topical cyclosporine has an effect on tear breakup time compared with placebo.

We do not know if topical corticosteroids (with or without antibiotics), including cyclosporine, have an effect on corneal staining (discoloration of the surface of the eye), compared with placebo. However, topical corticosteroid plus antibiotics probably result in a greater reduction in corneal staining than antibiotics alone.

Topical corticosteroid may not increase eye and eyelid irritation compared with placebo or antibiotics. No study comparing cyclosporine with placebo assessed harms.

What are the limitations of the evidence?
The lack of a universal or standardized scale for assessing the symptoms and/or signs of blepharitis is the major reason for a large variation in the design of these tools across studies. Harms, both short and long term, associated with the use of topical steroids and other immunosuppressants, should be thoroughly assessed in future trials to provide guidance before clinicians devise a treatment plan. High-quality trials are needed as our confidence in the evidence in this review is limited by the small number of studies for most comparisons, and because not all studies provided data about everything that we were interested in.

How up‐to‐date is the evidence?
The evidence is current to 6 April 2025.