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Table.  
Symptomatic Improvement Based on Prior Treatments
Symptomatic Improvement Based on Prior Treatments
1.
American Academy of Ophthalmology Cornea/External Disease PPP Panel. Preferred Practice Pattern guidelines: blepharitis PPP, limited revision, October 2011. http://one.aao.org/preferred-practice-pattern/blepharitis-ppp--limited-revision-october-2011. Accessed April 1, 2013.
2.
Kanoh  S, Rubin  BK.  Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev. 2010;23(3):590-615.
PubMedArticle
3.
Luchs  J.  Azithromycin in DuraSite for the treatment of blepharitis. Clin Ophthalmol. 2010;4:681-688.
PubMedArticle
4.
Tabbara  KF, al-Kharashi  SA, al-Mansouri  SM,  et al.  Ocular levels of azithromycin. Arch Ophthalmol. 1998;116(12):1625-1628.
PubMedArticle
5.
Bakar  O, Demircay  Z, Toker  E, Cakir  S.  Ocular signs, symptoms and tear function tests of papulopustular rosacea patients receiving azithromycin. J Eur Acad Dermatol Venereol. 2009;23(5):544-549.
PubMedArticle
6.
Igami  TZ, Holzchuh  R, Osaki  TH, Santo  RM, Kara-Jose  N, Hida  RY.  Oral azithromycin for treatment of posterior blepharitis. Cornea. 2011;30(10):1145-1149.
PubMedArticle
Research Letter
January 2014

Oral Azithromycin for the Treatment of Meibomitis

Author Affiliations
  • 1Department of Ophthalmology, University of California, San Francisco
  • 5now with the Department of Ophthalmology and Visual Science, University of Michigan Kellogg Eye Center, Ann Arbor
  • 2Francis I. Proctor Foundation, University of California, San Francisco
  • 3Department of Ophthalmology, San Francisco General Hospital, San Francisco, California
  • 4Barnet-Dulaney-Perkins Eye Center, Phoenix, Arizona
JAMA Ophthalmol. 2014;132(1):121-122. doi:10.1001/jamaophthalmol.2013.5295

Common treatment regimens for meibomitis include eyelid hygiene, lubricants, topical antibiotics, topical steroids, and systemic medications.1 Azithromycin is a macrolide antibiotic with robust antimicrobial and anti-inflammatory properties,2 and topical azithromycin, 1%, ophthalmic solution (AzaSite) has been shown to be efficacious in treating anterior and posterior blepharitis.3 Azithromycin’s pharmacokinetic profile adds to its potential value in treating meibomitis: a single 1-g oral dose results in high conjunctival tissue and tear fluid concentrations that persist for at least 14 days.4 Pulsed oral azithromycin has been reported to improve ocular signs and symptoms in patients with papulopustular rosacea.5 Based on this, azithromycin has potential efficacy in treating meibomitis using a short, pulsed dosing regimen, and we have used azithromycin in this fashion for the treatment of symptomatic meibomitis. We performed a retrospective review of patients receiving oral azithromycin for meibomitis to determine its impact on relieving patients’ symptoms.

Methods

The medical records of all patients seen in one author’s (T.P.M.) clinic at the Francis I. Proctor Foundation between January 1, 2009, and December 31, 2010, and who were treated with oral azithromycin for symptomatic meibomitis were reviewed. Patients were excluded if they had unrelated ocular pathology likely contributing to symptoms or if no follow-up had been recorded at the time of review. Collected data included patient demographic characteristics, all recorded prior (failed) treatments, and all concurrent treatments used in combination with oral azithromycin. Azithromycin was dosed as 1 g orally once per week for 3 weeks. Time to follow-up, subjective improvement, and adverse events as seen on examination or per patient report were recorded.

Results

Thirty-two patients (19 female; mean age, 60 years) with meibomitis qualified for this study based on inclusion and exclusion criteria. All patients reported poor response to commonly prescribed treatments including topical antibiotics and steroids (Table), and all patients were treated with oral azithromycin as well as concurrent topical steroid treatment for the duration of the study period, most frequently with sulfacetamide sodium, 10%/prednisolone acetate, 0.2%, drops applied twice daily to the eyelid margins. Other concurrent treatments included warm compresses (13 patients [41%]), topical metronidazole (6 patients [19%]), and topical antibiotics (3 patients [9%]).

Twenty-four patients (75%) reported symptomatic improvement with their treatment regimen at their follow-up visit (mean time to follow-up, 5.6 weeks; range, 3-11 weeks). Of patients with previous failure of steroids, other antibiotics, or both, similar rates of symptomatic improvement were seen (Table). When analyzing patients who were treated solely with oral azithromycin and topical steroid without any other concurrent treatments, 8 (67%) reported symptomatic improvement, including 7 (64%) of those who had previous failure of topical steroid treatment (Table). The most commonly reported adverse effects included gastrointestinal upset (3 patients [9%]) and ocular discomfort (2 patients [6%]), none of which required discontinuing use of azithromycin.

Discussion

The results of our study support oral azithromycin as being efficacious in treating symptomatic meibomitis, particularly in patients who have had failure of other commonly prescribed interventions. All of our patients had a history of failure of other treatments, but 75% reported symptomatic improvement with a regimen including oral azithromycin. While all patients also received a topical steroid, similar numbers noted improvement even when controlling for those who had past failure of steroid treatment. Adverse effects were minimal and mild, supporting the safety of this intervention. Our results further support the results of a recent small prospective study of 13 patients receiving pulsed oral azithromycin for treatment of nonrosacea posterior blepharitis, which showed similar improvement in patients’ symptoms and clinical signs.6 Based on our study as well as the limited evidence in the current literature, oral azithromycin appears to be a valuable tool in the treatment of meibomitis and further prospective studies would be justified to better assess efficacy and duration of effect.

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Article Information

Corresponding Author: Jonathan B. Greene, MD, Department of Ophthalmology and Visual Science, University of Michigan Kellogg Eye Center, 1000 Wall St, Ann Arbor, MI 48105 (jbgreene@med.umich.edu).

Published Online: November 7, 2013. doi:10.1001/jamaophthalmol.2013.5295.

Author Contributions: Dr Greene had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition of data: Greene.

Analysis and interpretation of data: Greene, Jeng, Margolis.

Drafting of the manuscript: Greene, Margolis.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Greene.

Administrative, technical, or material support: Jeng, Margolis.

Study supervision: Jeng, Fintelmann, Margolis.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by That Man May See, Inc, Research to Prevent Blindness, and grant R01 FD003708-01 from the US Food and Drug Administration (Dr Jeng).

Role of the Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

References
1.
American Academy of Ophthalmology Cornea/External Disease PPP Panel. Preferred Practice Pattern guidelines: blepharitis PPP, limited revision, October 2011. http://one.aao.org/preferred-practice-pattern/blepharitis-ppp--limited-revision-october-2011. Accessed April 1, 2013.
2.
Kanoh  S, Rubin  BK.  Mechanisms of action and clinical application of macrolides as immunomodulatory medications. Clin Microbiol Rev. 2010;23(3):590-615.
PubMedArticle
3.
Luchs  J.  Azithromycin in DuraSite for the treatment of blepharitis. Clin Ophthalmol. 2010;4:681-688.
PubMedArticle
4.
Tabbara  KF, al-Kharashi  SA, al-Mansouri  SM,  et al.  Ocular levels of azithromycin. Arch Ophthalmol. 1998;116(12):1625-1628.
PubMedArticle
5.
Bakar  O, Demircay  Z, Toker  E, Cakir  S.  Ocular signs, symptoms and tear function tests of papulopustular rosacea patients receiving azithromycin. J Eur Acad Dermatol Venereol. 2009;23(5):544-549.
PubMedArticle
6.
Igami  TZ, Holzchuh  R, Osaki  TH, Santo  RM, Kara-Jose  N, Hida  RY.  Oral azithromycin for treatment of posterior blepharitis. Cornea. 2011;30(10):1145-1149.
PubMedArticle
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