Know when and what is available to prescribe

The use of oral and topical antibiotics is well within the scope of optometry. That said, I would argue that they can often be improperly used by some and forgotten by many in the treatment of dry eye disease (DED), as so many effective targeted options exist for the chronic condition.

As a result, this month’s column focuses on both when to prescribe antibiotics and the types available.

When to prescribe

Optometrists should consider oral and topical antibiotics when the DED patient has meibomian gland dysfunction (MGD), blepharitis and/or rosacea. These patients have an overabundance of bacterial colonization producing toxic compounds and pro-inflammatory lipases and matrix metalloproteinases (MMP).¹

As a brief reminder, antibiotics help to break the cycle of poor meibum consistency, bacterial infection, toxin production, inflammation, and subsequent tear film instability.¹

What to prescribe

Both tetracyclines and azithromycin are used specifically because of their antimicrobial, anti-MMP, and anti-inflammatory properties.¹ The topical or oral antibiotics prescribed for patients who have DED caused by underlying MGD and blepharitis are:*

• Azithromycin (oral). This is shown effective at improving both the clinical signs and symptoms of posterior blepharitis.² It is typically prescribed at 250 mg once daily for five days.
• Azithromycin (topical). This is shown to relieve MGD signs and symptoms and restore meibomian gland secretion lipid properties toward normal.³
• Doxycycline (oral). This is reported to improve MGD over a few months of use.⁴ It is typically prescribed at 20 mg, 50 mg, or 100 mg once daily for 30 days.
• Minocycline (oral). Although, not typically used in the optometry setting, it is reported that three months of oral minocycline resulted in clinical improvements in all meibomianitis signs.⁵

* For information on individual efficacy and side effects, visit PubMed.

Remember to discuss common side effects when prescribing oral antibiotics. With use of both tetracyclines and azithromycin, gastrointestinal distress and diarrhea can be a concern, as can yeast infections with our female patients.

Specifically, with tetracyclines, we need to caution patients that they will be photosensitive, and that it may cause hormonal birth control to be less effective.

A consideration

Oral and topical antibiotics should be a consideration and not automatic in the patients described above. This is because current research supports that they have short-term positive effects on signs and symptoms in relation to MGD/blepharitis and rosacea. (Public health risk regarding overuse of antibiotics and resultant resistance is another factor.) With appropriate antibiotic use, it is important to continue utilizing other MGD and blepharitis treatments, such as lid hygiene, to best help our patients. OM

References

1. Vernhardsdottir RR, Magno MS, Hynnekleiv L, et al. Antibiotic treatment for dry eye disease related to meibomian gland dysfunction and blepharitis - A review. Ocul Surf. 2022;26:211-221. doi: 10.1016/j.jtos.2022.08.010.
2. Yildiz E, Yenerel NM, Turan-Yardimci A, Erkan M, Gunes P. Comparison of the Clinical Efficacy of Topical and Systemic Azithromycin Treatment for Posterior Blepharitis. J Ocul Pharmacol Ther. 2018;34(4):365-372. doi: 10.1089/jop.2017.0095. Epub 2018 Mar 1.
3. Foulks GN, Borchman D, Yappert M, Kim SH, McKay JW. Topical azithromycin therapy for meibomian gland dysfunction: clinical response and lipid alterations. Cornea. 2010;29(7):781-8. doi: 10.1097/ICO.0b013e3181cda38f.
4. Doughty MJ. On the prescribing of oral doxycycline or minocycline by UK optometrists as part of management of chronic Meibomian Gland Dysfunction (MGD). Cont Lens Anterior Eye. 2016;39(1):2-8. doi: 10.1016/j.clae.2015.08.002. Epub 2015 Sep 4.
5. Aronowicz JD, Shine WE, Oral D, Vargas JM, McCulley JP. Short term oral minocycline treatment of meibomianitis. Br J Ophthalmol. 2006l;90(7):856-60.doi: 10.1136/bjo.2006.091579.

DR. KOETTING is a clinical instructor at the University of Colorado School of Medicine. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active American Optometric Association member, and she consults for multiple companies. Email her at Dr.CeceliaKoetting@gmail.com.