Clogged meibomian glands via

Treating meibomian gland dysfunction has been an uphill battle for most doctors and their patients.  As the leading cause of Dry Eye Syndrome, meibomian glands that are blocked, congested, inflamed, or otherwise malfunctioning can result in symptoms ranging from redness, foreign body sensation, filmy vision, watering, dryness, and even itching (especially along the lash line).  Treatment options usually consist of daily warm massages, eyelid cleansers, and nutritional supplements like fish oil to try to unblock the meibomian glands and re-establish normal tear film release with regular blinks.  But even with the most deliberate daily approach to these treatments, they sometimes fall very short of success and doctors have looked towards oral antibiotics with anti-inflammatory properties to help encourage better meibomian gland secretion. The go-to oral treatment has traditionally been oral doxycycline, dosed for typically 1 month at a time.  A new study published in the British Journal of Ophthalmology suggests it is time for doctors to consider a more effective alternative to doxycycline -- oral azithromycin.  Both antibiotics have the added benefit of reducing inflammation around the oil glands of the eyelid in addition to their antibiotic properties, making them ideal for the treatment of eyelid inflammation.

Inflamed lid margin with meibomian gland dysfunction -- a great candidate for oral antibiotics and their anti-inflammatory properties!

Methods

The study followed 110 patients with meibomian gland dysfunction who were randomly split in to 2 trial groups.  One group received current standard of care: 200 mg oral doxycycline for 1 month.  The other treatment group received a Z-pak dosage of azithromycin: 500mg on day one, followed by 250 mg per day for the next 4 days.  Both treatment groups continued to use warm compress massages and artificial tears for symptoms.  Patients were followed at 1 week, 1 month, and 2 months post-treatment, and both their symptoms and signs of dry eye/meibomian gland dysfunction were assessed.

Results

Both groups showed statistically significant improved symptoms and signs following oral treatment. The azithromycin group showed superior clinical improvement on two endpoints compared to oral doxycycline: improved conjunctival redness and improved ocular surface staining.  There was no statistical difference in the patient rated symptom improvement between the azithromycin and doxycycline arms of the study.  There were more reported GI side effects (upset stomachs) with doxycycline use compared to azithromycin. At the 1 month follow-up visit 26% of those patients taking doxycycline reported GI upset, while only 4% of the azithromycin group reported stomach issues.

Take Home

Given the equitable symptom response and possibly even superior clinical sign improvement with azithromycin use, a paradigm shift to use oral azithromycin when possible over oral doxycycline seems warranted.  Not only was the oral azithromycin better tolerated by patients, but taking 5 days of an oral antibiotic will always be better for compliance and patient lifestyle than having to  take 1 month of a medication.  Other great patient benefits are that oral azithromycin dosed in Z-pak form is a well-priced generic and  typically very well covered by medical insurances, whereas oral doxycycline has been suffering from shortages recently and tends to be higher in cost.  A quick internet search in my area puts a 5 day Z-pak of 250mg oral azithromycin at $9.99 while a month of 100mg oral doxycyline (dosed BID to get the needed 200mg amount) costs over $40.  The study did not follow-up with patients past 2 months, so we do not know how long the positive effects of oral antibiotic treatment for MGD will typically last, but we do know that at the 2 month interval the azithromycin group was still performing on par or better than the oral doxycycline group on scored symptoms and signs even though they had not taken any medication in 7 weeks.