Assessment of efficacy of topical azithromycin 1.5 per cent ophthalmic solution for the treatment of meibomian gland dysfunction

The topical azithromycin meibomian gland dysfunction survey: The effect of topical azithromycin on signs and symptoms of meibomian gland dysfunction

INTRODUCTION

The aim of this study was to assess the long-term effects of topical azithromycin on signs, symptoms and self-management of meibomian gland dysfunction (MGD).

METHODS

Forty participants were assessed for MGD and its effect on the fluorescein tear break-up time (FTBUT). Participants were treated with topical azithromycin twice daily for 2 weeks and then once daily for a further 2 weeks. One year after treatment, 31 participants completed a survey assessing pre- and post-treatment effect on symptoms, lifestyle and self-treatment methods.

RESULTS

Following treatment, there was a significant reduction in MGD grading from a median of grade 2 to grade 0 (z = 4.40, p < 0.0001) and an increase in FTBUT from a median of 3-8 s (z = 4.75, p < 0.0001). One year afterwards, the survey showed a significant improvement in symptoms (sensitivity to light, grittiness, burning, blurred vision, all p < 0.03) and reduction in required self-treatments (lid wipes, tear substitutes, both p < 0.03). There was also a reduced impact on lifestyle (reading, night driving, computer use and watching television, all p < 0.0001) and in all environmental conditions (all p < 0.0001).

CONCLUSIONS

This study confirms the positive effect of topical azithromycin on MGD and shows it has a long-term impact on symptoms, self-treatment methods and lifestyle. This has implications for both chair time and healthcare costs when managing patients with MGD. Pending further clinical trials in a larger population with different demographics, topical azithromycin should be considered by all eyecare practitioners as a viable pharmacological treatment when managing MGD.

Efficacy of meibomian gland expression combined with Home-Based therapy in the management of dry eye Disease: A systematic review and Meta-Analysis

PURPOSE

To compare the effectiveness of meibomian gland expression (MGX) combined with home-based therapy versus home-based therapy alone for the treatment of dry eye disease (DED) caused by meibomian gland dysfunction (MGD).

METHODS

A systematic review of randomized controlled studies (RCTs), reporting the effects of MGX combined with home-based therapy in 2 databases, PubMed and Web of Science, was performed according to the PRISMA statement. The search period was until August 20, 2023. According to the heterogeneity, a random or fixed effects model was performed in the meta-analysis. The standardized mean difference (SMD) was calculated to analyze dry eye symptoms (DES) score, tear film break-up time (TBUT), total corneal fluorescein staining (tCFS) and meibomian glands expressibility (MGE). All analyses were performed by RevMan Web, version 5.7. The Cochrane risk of bias tool was used to analyze the quality of the studies selected.

RESULTS

Two RCTs with a total of 99 patients were included. The studies reported that MGX combined with home-based therapy improves DES score, TBUT, tCFS and MGE compared to the home-based therapy. However, the meta-analysis indicated that MGX combined with home-based therapy only seems to be beneficial in reducing DES score (SMD -0.49; 95 % CI: -0.89 to -0.08; P = 0.02; I2 = 0 %). In addition, although TBUT, tCFS and MGE reported a slight trend in favor of MGX combined with home-based therapy, it was non-significant.

CONCLUSIONS

While MGX combined with home-based therapy seem to show some evidence of alleviating dry eye symptoms, there is insufficient evidence to conclude the effects of this treatment definitively particularly in improving dry eye signs caused by MGD, such as TBUT, tCFS and MGE. Therefore, further RCTs are needed to elucidate these results.

Ductal Hyperkeratinization and Acinar Renewal Abnormality: New Concepts on Pathogenesis of Meibomian Gland Dysfunction

Meibomian gland dysfunction (MGD) is a functional and morphological disorder of the meibomian glands which results in qualitative or quantitative alteration in meibum secretion and is the major cause of evaporative dry eye (EDE). EDE is often characterized by tear film instability, increased evaporation, hyperosmolarity, inflammation, and ocular surface disorder. The precise pathogenesis of MGD remains elusive. It has been widely considered that MGD develops as a result of ductal epithelial hyperkeratinization, which obstructs the meibomian orifice, halts meibum secretion, and causes secondary acinar atrophy and gland dropout. Abnormal self-renewal and differentiation of the acinar cells also play a significant role in MGD. This review summarizes the latest research findings regarding the possible pathogenesis of MGD and provides further treatment strategies for MGD-EDE patients.

Combined intense pulsed light and low-level light therapy for the treatment of refractory Meibomian gland dysfunction

PURPOSE

To evaluate the efficacy of combined Intense Pulsed Light (IPL) and Low-Level Light Therapy (LLLT) in treatment of Meibomian Gland Dysfunction (MGD).

METHODS AND ANALYSIS

In this prospective study, 70 patients with refractory MGD were enrolled; group 1 received 3 consecutive sessions of IPL + LLLT treatment using Eye-light® on day 1, day 15 and day 45; group 2 received hyaluronate sodium 2 mg/ml drops 3 times a day for 6 months. Patients underwent at baseline, and after 3 and 6 months Ocular Surface Disease Index (OSDI) questionnaire, Symptom Assessment in Dry Eye (SANDE), tear-film breakup time (TBUT), fluorescein ocular surface staining, meibum expressibility and quality evaluations. Keratograph 5M (Oculus, Germany) was used to assess NIBUT, tear meniscus height (TMH), meibography, and bulbar redness score.

RESULTS

At 6 months a significant improvement of OSDI (p = 0.03), SANDE (p = 0.02), NIBUT (p = p < 0.0001), TMH (p = 0.04), TBUT (p = 0.02), corneal-conjunctival staining score (p = 0.02), lid margin score (p < 0.0001), and bulbar redness score (p = 0.001) were recorded in group 1. Comparing the two groups, statistically significant differences were observed at 6 months in TBUT (p = 0.03), lid margin score (p < 0.001), Meibum expressibility (p = 0.03) and NIBUT (p < 0.001). No adverse events were recorded throughout the follow-up period.

CONCLUSION

This study confirmed the efficacy and safety of combined IPL and LLLT demonstrating its superiority compared to topical treatment.

A Practical Approach to Severity Classification and Treatment of Dry Eye Disease: A Proposal from the Mexican Dry Eye Disease Expert Panel

Dry eye disease (DED) has a higher prevalence than many important systemic disorders like cardiovascular disease and diabetes mellitus, representing a significant quality of life burden for the affected patients. It is a common reason for consultation in general eye clinics worldwide. Nowadays, the diagnostic and therapeutic approach at the high corneal and ocular surface specialty level should be reserved for cases of severe and chronic dry eye disease associated with systemic autoimmune diseases or complicated corneal and ocular surface pathologies. In such cases, the diagnostic and therapeutic approach is often complex, elaborate, time-consuming, and costly due to the use of extensive dry eye questionnaires, noninvasive electronic diagnostic equipment, and clinical laboratory and ancillary tests. However, other eye care specialists attend a fair amount of DED cases; therefore, its diagnosis, classification, and management should be simple, practical, achievable, and effective. Considering that many patients attending non-specialized dry eye clinics would benefit from better ophthalmological attention, we decided to elaborate a practical DED classification system based on disease severity to help clinicians discriminate cases needing referral to subspecialty clinics from those they could attend. Additionally, we propose a systematic management approach and general management considerations to improve patients' therapeutic outcomes according to disease severity.

Efficacy of Azithromycin Eyedrops for Individuals With Meibomian Gland Dysfunction-Associated Posterior Blepharitis

PURPOSE

To examine the safety and efficacy of azithromycin eyedrops in Japanese individuals with meibomian gland dysfunction (MGD)-associated posterior blepharitis.

METHODS

Individuals with MGD-associated posterior blepharitis who visited the Itoh Clinic, Saitama, Japan, were randomly assigned to receive azithromycin (1%) eyedrops (AZM group, 16 eyes of 16 patients) or preservative-free artificial tears (control group, 20 eyes of 20 patients) for 2 weeks. All subjects also applied a warming eyelid compress twice per day. Subjective symptoms (Standardized Patient Evaluation of Eye Dryness [SPEED] score), lipid layer thickness (LLT) and interferometric pattern of the tear film, plugging and vascularity of the lid margin, noninvasive break-up time of the tear film (NIBUT) and fluorescein-based break-up time of the tear film (TBUT), corneal-conjunctival fluorescein staining score, tear meniscus height, meibum grade, meiboscore, tear osmolarity, and Schirmer test value were determined before and after treatment. Side effects of treatment were also recorded.

RESULTS

In the AZM group, SPEED score, LLT, interferometric pattern, plugging and vascularity of the lid margin, NIBUT, TBUT, meibum grade, and tear osmolarity were significantly improved after treatment compared with baseline. The SPEED score, interferometric pattern, plugging, vascularity, meibum grade, and tear osmolarity were also significantly improved after treatment in the AZM group compared with the control group. Common side effects in the AZM group were transient eye irritation and blurred vision.

CONCLUSION

Azithromycin eyedrops improved eyelid inflammation, the quality and quantity of the lipid layer of the tear film, and tear film stability. Such eyedrops thus seem to be a safe and effective treatment for MGD-associated posterior blepharitis.

The Role of Topical Azithromycin in the Treatment of Meibomian Gland Dysfunction

PURPOSE

The efficacy of topical azithromycin (AZ) supplementation to systemic AZ has not been studied. This study evaluates the efficacy of topical AZ supplementation to systemic AZ, warm compresses, artificial tears, and lid scrubs for the treatment of meibomian gland dysfunction (MGD).

METHODS

Eighty-five patients with stage 4 MGD were enrolled in the study. The patients enrolled into the study were divided into 2 groups. Group 1 comprised 55 patients who received preservative-free topical 1.5% AZ administered as a unit dose, and group 2 comprised 30 patients who did not receive topical AZ. Both groups were prescribed artificial tear eye drops and systemic AZ. Fluorescein tear film breakup time (TBUT), corneal staining, Ocular Surface Disease Index (OSDI) symptom scores, and meibum quality were evaluated at baseline and after 1 and 3 months.

RESULTS

The mean age of patients in group 1 was 48.3 ± 13.4 years (25 men and 30 women) and in group 2 was 50.7 ± 10.2 years (12 men and 18 women). After treatment at the first and third month, group 1 showed significant improvement in mean TBUT, mean corneal staining score, meibum quality, and mean OSDI scores compared with baseline (P < 0.05). In group 2, only the OSDI score and meibum quality improved significantly after treatment compared with baseline (P < 0.05).

CONCLUSIONS

These results demonstrate clinically and statistically greater improvement in MGD-associated signs and symptoms with the addition of topical AZ to the systemic treatment.

A Review on Evidence-Based Treatments for Meibomian Gland Dysfunction

OBJECTIVES

To evaluate recent studies on available therapies for meibomian gland dysfunction (MGD).

METHODS

A literature search on recent publications, within the last five years, concerning treatment options for MGD was performed.

RESULTS

A total of 35 articles were reviewed after curation by the authors for relevance. In general, all modalities of treatments were shown to have clinical efficacy in alleviating dry eye signs and symptoms, although the extent of improvement and persistency of outcomes varied between the different treatments. Evidence from published studies demonstrate that thermal pulsation produces the longest lasting effect per treatment, but it also incurs the highest per-treatment cost. Reusable methods for warm compress with lipid/semi-fluorinated alkane-containing eye drops are recommended as first-line treatment for mild-to-moderate dry eye patients, because this option is most technically feasible and cost-effective in clinical practice. Intense pulsed light (IPL) therapy and thermal pulsation may be suitable as second line for patients unresponsive to warm compress therapy; however, their respective limitations need to be considered. For refractory MGD with features of periductal fibrosis or severe blepharitis, supplementary treatment with meibomian gland probing or oral antibiotics may be used.

CONCLUSIONS

All eight forms of treatments, including self-applied eyelid warming, thermal pulsation, IPL, MG probing, antibiotics, lipid-containing eye drops, and perfluorohexyloctane, were effective against MGD, although with varying extent of clinical improvements. A better understanding on the mechanisms of actions may guide physicians to make better treatment decisions targeting the root causes.

Systematic review and meta-analysis of treating meibomian gland dysfunction with azithromycin

To systematically review studies of managing meibomian gland dysfunction (MGD) with azithromycin and pool clinical outcomes to show its effectiveness. Eligible studies were retrieved from five main electronic databases. Symptom score was the primary outcome, while clinical signs and objective measurements were secondary outcomes. Pooled rates for adverse events were also calculated. Improvements in each outcome after administering either oral azithromycin (OA) or topical azithromycin (TA) were pooled and measured by standard mean difference (SMD) to show the overall effectiveness. Then the effectiveness was sub-grouped by TA and OA. In addition, pooled outcomes after administering TA and oral doxycycline (OD) were compared with assess their effectiveness. Finally, 18 eligible studies were included. The overall pooled symptom scores were significantly reduced after administering both TA and OA [P < 0.0001; SMD = 1.54 (95% CI: 1.15–1.92)]. Similarly, the overall combined eyelid signs, plugging of the meibomian gland, meibum quality, and tear secretion were also distinctly improved. However, significant improvements for tear break-up time (TBUT) and corneal staining (CS) were achieved by TA (TBUT: P = 0.02; CS: P = 0.02) but not by OA (TBUT: P = 0.08; CS: P = 0.14). The pooled adverse event rates for TA and OA were 25% and 7%, respectively. Moreover, TA was comparable to OD to treat MGD regarding symptom score, TBUT and tear secretion. This study showed that MGD could be treated effectively with oral or topical azithromycin by improving symptoms, clinical signs, and stabilization of tear film. Topical azithromycin seemed to be superior over oral azithromycin or doxycycline in improving the quality of tear film in the short term.

Composition and Diversity of Bacterial Community on the Ocular Surface of Patients With Meibomian Gland Dysfunction

Purpose

To investigate the composition and diversity of bacterial community on the ocular surface of patients with meibomian gland dysfunction (MGD) via 16S rDNA sequencing.

Methods

Forty-seven patients with MGD, who were divided into groups of mild, moderate, and severe MGD, and 42 sex- and age-matched participants without MGD (control group) were enrolled. Samples were collected from the upper and lower conjunctival sac of one randomly chosen eye of each participant. Through sequencing the hypervariable region of 16S rDNA gene obtained from samples, differences in the taxonomy and diversity between groups were compared.

Results

Principle coordinate analysis showed significantly distinct clustering of the conjunctival sac bacterial community between the severe MGD group and the other groups. At the phylum level, the relative abundances of Firmicutes (31.70% vs. 19.67%) and Proteobacteria (27.46% vs. 14.66%) were significantly higher (P < 0.05, Mann-Whitney U), and the abundance of Actinobacteria (34.17% vs. 56.98%) was lower in MGD than controls (P < 0.05, Mann-Whitney U). At the genus level, the abundances of Staphylococcus (20.71% vs. 7.88%) and Sphingomonas (5.73% vs. 0.79%) in patients with MGD were significantly higher than the controls (P < 0.05, Mann-Whitney U), while the abundance of Corynebacterium (20.22% vs. 46.43%) was significantly lower (P < 0.05, Mann-Whitney U). The abundance of Staphylococcus was positively correlated with the meiboscores in patients with MGD (r = 0.650, P < 0.001, Spearman).

Conclusions

Patients with MGD can have various degrees of bacterial microbiota imbalance in the conjunctival sac. Staphylococcus, Corynebacterium, and Sphingomonas may play roles in the pathophysiology of MGD.

Management of meibomian gland dysfunction: a review

Meibomian gland dysfunction is the leading cause of evaporative dry eye disease and is one of the most common conditions encountered by eye care providers. The disorder is characterized by obstruction of the meibomian gland terminal ducts and/or changes in their glandular secretion, resulting in changes in tear film stability, inflammation, and symptoms of irritation. There is no gold standard treatment for meibomian gland dysfunction, but rather a diversity of options. Conservative measures include warm compresses and lid hygiene, but there is growing interest and need for medical treatments and procedures. Potential medical treatments include antibiotics, nonsteroidal and steroidal anti-inflammatory agents, essential fatty acid supplementation, hormone therapy, and control of Demodex infestation. Procedures include intraductal meibomian gland probing, the use of electronic heating devices, intense pulsed light therapy, and intranasal neurostimulation. We provide an update on meibomian gland dysfunction treatments based on recent studies.