Eyeworld

FALL 2026 | EYEWORLD | 65 C Relevant disclosures Donaldson: AbbVie, Alcon, Bausch + Lomb, Dompé, Science Based Health, Tarsus Pharma- ceuticals Pflugfelder: None Seitzman: Dompé, Kedrion Bio- pharma, Tarsus Pharmaceuticals Contact Donaldson: KDonaldson@med.miami.edu Pflugfelder: stevenp@bcm.edu Seitzman: Gerami.Seitzman@ucsf.edu procedures can be helpful for chronic disease and surgical preparation of the ocular surface." For patients with meibomian gland disease experiencing blepharitis, Dr. Pflugfelder said he'll prescribe warm compresses and mas- sage, thermoexpression treatments (LipiFlow, Thermal 1-Touch [OcuSOFT], TearCare [Sight Sciences]), nutritional supplements, such as omega-3 and omega-6 essential fatty acids, oral doxycycline or azithromycin, and/or intense pulsed light therapy. When it comes to mechan- ical treatments, like thermal pulsation or auto- mated heat and forceps, he finds symptomatic improvement lasts weeks to months. Dr. Pflugfelder noted that while the treat- ments are different, some patients have both anterior and posterior disease, so combined therapy is needed. A key point for blepharitis treatment is early intervention. "Chronic inflammation leads to gland dropout, chronic changes in lid architec- ture, lid margin vascularization, and lash loss," Dr. Donaldson said. Despite the progress that's been made for more effective and targeted blepharitis treat- ment, Dr. Donaldson said gaps remain in the following areas: treatment of durable disease modification and prevention strategies, treat- ment of mixed-mechanism disease, and treat- ment of severe gland atrophy. "We also need a better solution for patient adherence/compliance (chronic care fatigue) and earlier detection tools (preclinical MGD). Standardized treatment algorithms that provide the best results (TFOS DEWS III and the ASCRS Preoperative OSD Algorithm) have helped with this, but we're still working on making this routine and easier for the average ophthalmol- ogist to incorporate into everyday practice," Dr. Donaldson said. Looking ahead Just as there have been some advances in blepharitis treatment options in recent years, Dr. Donaldson said she sees major shifts for it in the future, "including a change for more targeted treatments focusing on treatment of Demodex, the biofilm, direct treatment of inflammation, and MGD," she explained. "I also see more of a focus on early in- tervention and screening before cataract or corneal-based refractive surgery," she continued. "Additionally, there has been a shift toward preventing progression rather than reacting to end-stage damage. I think there will be more routine office-based treatments in combination with specifically targeted medical treatments. Pharma treatments will continue to expand, including targeted treatments like XDEMVY and AZR-MD-001, and there will likely be more combination regimens for optimizing results." AZR-MD-001 (selenium sulfide ophthalmic, Azura Ophthalmics) is a multi-mechanism drug; it serves as a keratolytic, is anti-Demodex, and reduces biofilm. Dr. Donaldson called AZR-MD-001 "excit- ing due to its multi-mechanism activity." "Many cases of chronic blepharitis have keratinized lid margins, and for that reason we are looking forward to trialing agents like AZR-MD-001," Dr. Seitzman said. Dr. Pflugfelder envisions AZR-MD-001 being "used as an adjunct ther- apy to remove orifice plugging that may make other therapies more effective. It remains to be determined if it will be a standalone therapy," he said. NCX 4251 (fluticasone propionate, Nicox) works through a novel anti-inflammatory path- way with potential to reduce neurogenic inflam- mation and to address symptoms beyond sur- face disease, Dr. Donaldson said. Dr. Seitzman said she hasn't heard much about NCX 4251 but said she hopes it will be preservative free. "In general, most chronic blepharitis requires a steroid at some point (or at many points), and this will be another interesting medication to watch," Dr. Seitzman said. Dr. Pflugfelder thinks that NCX 4251 has the potential to be a safer, more convenient method of steroid delivery than drops or conventional ointments. "It's exciting that we are seeing more of a shift toward mechanism-specific and combi- nation therapy and moving beyond 'lid scrubs forever,'" Dr. Donaldson said. Dr. Pflugfelder said some mechanisms have yet to be discov- ered, such as for MGD. "The pathogenesis of most types of MGD has not been established," he said. In general, Dr. Seitzman said it's important to remember that blepharitis doesn't go away. "For most subtypes, this is a chronic, recurring process," she said. "Some patients do well with episodic treatment; others require chronic treat- ment, and here, identification of the lowest-fre- quency, lowest-potency, least-toxic regimen that controls their symptoms is key."

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