Azitromicina

1. Oral azithromycin versus doxycycline in meibomian
gland dysfunction: a randomised double masked
open label clinical trial
Mohsen Bahmani Kashkouli,1
Ali Jalili Fazel,1
Victoria Kiavash,1
Marzieh Nojomi,2
Leila Ghiasian3
1
Eye Research Center, Iran
University of Medical Sciences,
Tehran, Iran
2
Epidemiology and Community
Medicine Department, Iran
University of Medical Sciences,
Tehran, Iran
3
Eye Research Center, Rassoul
Akram Hospital, Iran University
of Medical Sciences, Tehran,
Iran
Correspondence to
Dr Mohsen Bahmani
Kashkouli, Eye Research
Center, Rassoul Akram
Hospital, Sattarkhan-Niayesh
St, Tehran 14455-364, Iran;
bahmanik@yahoo.com
Received 18 April 2014
Revised 27 June 2014
Accepted 26 July 2014
To cite: Kashkouli MB,
Fazel AJ, Kiavash V, et al. Br
J Ophthalmol Published
Online First: [please include
Day Month Year]
doi:10.1136/bjophthalmol-
2014-305410
ABSTRACT
Background/aims To assess the efficacy and safety of
oral azithromycin compared with oral doxycycline in
patients with meibomian gland dysfunction (MGD) who
had failed to respond to prior conservative management.
Methods 110 patients (>12 years old) with MGD were
randomly assigned to receive either oral 5-day
azithromycin (500 mg on day 1 and then 250 mg/day)
or 1-month doxycycline (200 mg/day). They also
continued eyelid warming/cleaning and artificial tears.
A score comprising five symptoms and seven signs
(primary outcome) was recorded prior to treatment and
at 1 week, and 1 and 2 months after treatment. Total
score was the sum of both scores at each follow-up.
Side effects were recorded and overall clinical
improvement was categorised as excellent, good, fair or
poor based on the percentage of change in the total
score.
Results Symptoms and signs improved significantly in
both groups (p=0.001). While improvement of
symptoms was not different between the groups, bulbar
conjunctival redness (p=0.004) and ocular surface
staining (p=0.01) were significantly better in the
azithromycin group. The azithromycin group showed a
significantly better overall clinical response (p=0.01).
Mild gastrointestinal side effects were not significantly
different between the groups except for the second visit,
when the doxycycline group had significantly more side
effects (p=0.002).
Conclusions Although both oral azithromycin and
doxycycline improved the symptoms of MGD, 5-day oral
azithromycin is recommended for its better effect on
improving the signs, better overall clinical response and
shorter duration of treatment.
Trial registration number NCT01783860.
INTRODUCTION
Meibomian glands have an important role in the
health of the ocular surface by secreting a lipid and
protein mixture into the tear film; this prevents
evaporation of the tear film,1 2
even though the
role of protein is less clear. Meibomian gland dys-
function (MGD) compromises the tear film and
meibum lipids which results in evaporative dry
eye.3 4
MGD is an extremely common and import-
ant cause of posterior blepharitis, the incidence of
which is probably underestimated.5 6
The leading cause of MGD is obstruction of MG
secondary to hyperkeratinisation of the duct epithe-
lium and accumulation of meibum, resulting in
inflammation and possibly an increased bacterial
colonisation of the lid margins.7
MGD may be
asymptomatic, only detectable by gland expression,
or, more often, present with dry eye symptoms.8
Common symptoms are foreign body and burning
sensation, red eye, tearing and photophobia.6
Common signs are loss of clarity and thickening of
expressed meibum, pouting or plugging of meibo-
mian gland orifices, meibomian gland drop out
detectable by meibography, increased eyelid margin
thickness and vascularity, eyelash loss, trichiasis and
vascular invasion.9
Most cases usually require conservative manage-
ment including warm compresses to provide appro-
priate meibum secretion, mechanical eyelid massage
and cleansing with shampoo and cotton buds to
remove excess debris, and artificial tears to continu-
ously lubricate the ocular surface.10 11
In severe and
refractory cases, however, antibiotics (topical and sys-
temic) with anti-inflammatory properties are pro-
posed.12 13
Tetracycline and its derivatives are
antimicrobials with the ability to decrease inflamma-
tion and inhibit matrix metalloproteinases.14
Doxycycline is a long acting analogue of tetracycline
which has been used to treat MGD through its
antimicrobial, anti-inflammatory and anti-
metalloproteinase properties, with fewer side effects
than tetracycline.6 15
A few studies have shown the
efficacy of azithromycin in chronic inflammatory dis-
eases such as MGD.16 17
Azithromycin inhibits
pro-inflammatory cytokines and is potent against
Gram-negative microorganisms.14
Topical and oral
azithromycin have recently been reported to improve
the sign and symptoms of MGD and posterior
blepharitis.12 14
Although previous studies have shown the effi-
cacy of both oral doxycycline and oral azithro-
mycin in the treatment of MGD, to the best of
our knowledge there has been no study compar-
ing their effects and side effects. Therefore, this
randomised double masked open label clinical
trial was designed to evaluate the efficacy
(symptom and sign scores) and safety (side
effects) of oral azithromycin compared with oral
doxycycline in patients with posterior blepharitis
who were unresponsive to the conservative man-
agement (eyelid warming/massage/cleaning and
artificial tears).
MATERIALS AND METHODS
Sample size was calculated to detect at least 1.8 dif-
ferences12 14
between the severity scores of two
groups across the time periods of the first and last
follow-up visit, considering type one error of 0.05
and power of 80%. This was 43 patients in each
Kashkouli MB, et al. Br J Ophthalmol 2014;0:1–6. doi:10.1136/bjophthalmol-2014-305410 1
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2. group. In order to overcome the problem of loss to follow-up,
the aim was to recruit 55 patients in each group (15% more
than the calculated sample size).
Block randomisation (four subjects per block) was used to
assign patients to the treatment groups. Simple randomisation
was used to assign the eye to the patient in the treatment group
by writing digit numbers (1 to 110) and right/left words on sep-
arate sealed papers which were then randomly chosen
(figure 1). One of the masked observers (AJF) secured the
sealed papers and another (VK) performed the examination and
scoring in all visits (figure 1).
All participants signed an informed consent. The Tehran
University of Medical Sciences ethics committee approved
the study. The study was performed at the Rassoul Akram
Hospital. It was registered and released with ClinicalTrials.gov
(NCT01783860). This research adhered to the tenets of the
Declaration of Helsinki.
Included were consecutive patients (over the age of 12 years)
with posterior blepharitis who had not responded to conservative
management: eyelid warming/massage/cleaning (4–5 min) twice a
day and artificial tears (four times a day). Exclusion criteria were:
taking systemic or topical antibiotic within 1 month prior to inclu-
sion, history of liver disease, pregnancy and breast feeding, contact
lens wearing, allergy to azithromycin or cyclines, vernal and atopic
keratoconjunctivitis, ocular and ocular adnexal surgery, altered lid
anatomy for any reason, and incomplete follow-up (missing any of
three pre-scheduled visits).
Severity of five main symptoms was measured on a 4-point
categorical scale (0–3) according to patients’ response to ques-
tions: itching, burning, foreign body sensation, dryness and
eyelid swelling (table 1). Slit lamp examination was performed
to assess and record the severity of seven signs on a 4-point cat-
egorical scale: meibomian gland secretion, number of plugged
gland orifices, conjunctival injection, lid margin redness, lid
margin debris, tear break up time (TBUT), and ocular surface
staining with fluorescein (table 1).
Meibomian gland expression was performed (digital pressure)
on the central third of the lower eyelid and graded on a 0–3
scale based on the worst type of secretion (clear, cloudy, turbid
clumps, solid paste).
Meibomian gland plugging was graded as follows: 0, clear
orifice of meibomian glands in the central part of the lower
eyelid; 1, less than one-third of the orifices contained turbid or
oily secretion; 2, between one-third and two-thirds of the ori-
fices contained turbid or oily secretion; 3, more than two-thirds
of the orifices contained turbid or oily secretion.
Bulbar conjunctival redness was graded as none, pink, light
red, and bright red based on slit lamp examination.
Lid margin redness was also graded as none, pink, light red,
and bright red based on the colour of the lower eyelid margin
on slit lamp examination.
Lid margin debris was scored based on the number of crusts
at the lower eyelid margin, included in this study even though it
is mostly present in anterior blepharitis.
TBUT was performed before ocular surface staining.
Fluorescein impregnated (single drop of saline) paper was
placed in the lower fornix, and patient was asked to gently blink
a few times and then stop blinking while being observed (blue
light of slit lamp) for the first break on the corneal surface tear
film. The time of the first split was recorded and graded on a
4-point categorical scale: grade 0 (>10 s), 1 (8–10s), 2 (5–7s),
and 3 (<5 s).
Ocular surface staining was immediately performed after
recording the TBUT using a 4-point categorical scale panel
(figure 2), which was a modification of panels introduced in the
Oxford grading scale18
in order to be compatible with grading
of the other signs. The patient’s upper eyelid was raised to
observe the entire cornea, and the temporal and nasal interpal-
pebral conjunctiva were assessed by asking the patient to look
nasally and temporally, respectively. The panel which best repre-
sented the number and pattern of dots on the cornea and con-
junctiva was selected and corresponding grade was recorded.
MGD was diagnosed based on having at least two symptoms
and two signs (one must be the presence of meibomian gland
signs) with a minimum severity score of 2 for each. All pretreat-
ment and post-treatment assessment and examinations were per-
formed by one observer who was masked to the type of
treatment. Patients were randomly (block randomisation of four
in each block) assigned to either a 5-day oral azithromycin
(Kimidarou Co., Tehran, Iran) course (500 mg on the first day
and then 250 mg per day for the following four days) or a
1-month oral doxycycline (Irandarou Co., Tehran, Iran) course
(100 mg twice a day). Doxycycline was instructed to be taken
with a full glass of water while sitting for a few hours before
going to bed and keeping a couple of hours between any supple-
ment and doxycycline. Patients were also instructed to continue
conservative management: eyelid warming/massage/cleaning
twice a day and artificial tears four times a day throughout the
study.
The symptom and sign scores were recorded prior to treat-
ment and three times after treatment: first visit (day 12; 1 week
after 5-day azithromycin), second visit (day 36–37; 1 month
after 5-day azithromycin and 1 week after 1-month doxycyc-
line), and third visit (day 60; 1 month after 1-month doxycyc-
line and 7 weeks after 5-day azithromycin) (figure 1). The
original plan was to have four post-treatment visits in which the
second (1 month after 5-day azithromycin) and third (1 week
after 1-month doxycycline) visits were a couple of days apart.
Since they were close to each other, the second visit was consid-
ered to be 1 month after 5-day azithromycin and 1 week after
1-month doxycycline.
Each patient’s symptoms or signs were given a score of 0
to 3. The symptom score of each subject was calculated by
adding the score (0–3) of five symptoms which resulted in a
range of 0–15. The sign score of each patient was also calcu-
lated by adding the score (0–3) of seven signs which resulted in
a range of 0–21. The total score (0–36) of each patent was cal-
culated and recorded by adding the scores of symptoms (0–15)
and signs (0–21) at each visit. Overall clinical responses were
categorised based on the percentage of reduction of total score
into four groups: excellent (76–100%), good (51–75%), fair
(26–50%), and poor (1–25%). Side effects of treatments were
also recorded at each visit.
Statistics
The χ2
and Student t-test were used to compare demographic
characteristics across the two intervention groups. The Student
t-test was used for comparing symptoms, signs and total mean
scores. The χ2
test was used to analyse the overall clinical
response and side effects. A p value of less than 0.05 was con-
sidered as statistically significant and 95% CI was used as a
measure of precision. Analysis was performed by a masked
observer (MN).
RESULTS
There were 110 patients, of whom 10 did not complete the
study according to the protocol (figure 1). Therefore, included
2 Kashkouli MB, et al. Br J Ophthalmol 2014;0:1–6. doi:10.1136/bjophthalmol-2014-305410
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3. for analysis were 100 patients (100 eyes) who were studied
between February 2013 and July 2013. The two groups were
matched for demographics (table 2).
Symptoms significantly improved in both groups (p=0.001,
95% CI −2.2 to −0.7). However, there was no significant differ-
ence between the groups at all post-treatment visits (table 3).
Both groups showed a significant improvement of clinical
signs (p=0.001, 95% CI −2.8 to −0.8). Comparison of the
second and third follow-up for each group showed only a sig-
nificant improvement of mean sign score in the azithromycin
group (p=0.01) and no significant difference in the other
scores. While mean sign scores were not significantly different
at the pretreatment and first post-treatment visits, they were sig-
nificantly less (better response) in the azithromycin group at the
second and third visits and consequently the mean total score
was better at the same times (table 3). Although the last
follow-up mean score of all seven signs was less (better
response) in the azithromycin than in the doxycycline group,
the difference was statistically significant in only conjunctival
redness and ocular surface staining (table 4).
Figure 1 Flow diagram of
participants in the trial of 5-day oral
azithromycin (group 1) versus 1-month
oral doxycycline (group 2) for
treatment of meibomian gland
dysfunction at different stages:
pretreatment and first (day 12; 1 week
after 5-day azithromycin), second (day
36–37; 1 month after 5-day
azithromycin and 6–7 days after
1-month doxycycline), and third (day
60; 1 month after 1-month doxycycline
and 7 weeks after 5-day azithromycin)
post-treatment visits.
Table 1 Grading of five symptoms (1–5) and seven signs (6–12) in 100 patients with meibomian gland disease
Symptom Grade 0 Grade 1 Grade 2 Grade 3
1. Itching None Awareness Desire to rub Frequent rub
2. Foreign body sensation None Awareness Desire to rub Desire to close eyelids
3. Dryness None Awareness Need drops Frequent drops
4. Burning None Awareness desire to rub Frequent rub
5. Eyelid swelling None Noticeable Obvious Decrease in palpebral fissure
6. MG secretion (central lower eyelid) Clear Cloudy Turbid with clumps Solid with paste
7. Plugged MG orifice (middle lower eyelid) None Less than 1/3 1/3–2/3 More than 2/3
8. Bulbar conjunctival redness None Pink Light red Bright red
9. Eyelid margin redness None Pink Light red Bright red
10. Eyelid margin debris None 1–5 6–10 More than 10
11. Tear breakup time (second) >10 8–10 5–7 <5
12. Ocular surface staining 4-point categorical panels (figure 2)
MG, meibomian glands.
Kashkouli MB, et al. Br J Ophthalmol 2014;0:1–6. doi:10.1136/bjophthalmol-2014-305410 3
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4. While the azithromycin group showed excellent (6%) and
good (46%) responses in 52% of patients, the doxycycline
group had an excellent response in none and a good response in
32% of patients (p=0.01). On the other hand, while there were
more fair responses in the azithromycin (38%) than in the doxy-
cycline group (34%), there were three times more poor
responses in the doxycycline (34%) than in the azithromycin
(10%) group.
Both groups had a few gastrointestinal side effects (nausea,
abdominal cramp, diarrhoea and decreased appetite), which
were not significantly different at all follow-up visits except for
the second visit (immediately after termination of the doxycyc-
line course), when there were significantly more side effects in
the doxycycline (13/50, 26%) than in the azithromycin (2/50,
4%) group (table 5). All were temporary and did not result in
stopping the medications.
DISCUSSION
This is, to the best of our knowledge, the first randomised clin-
ical trial comparing oral doxycycline and azithromycin in the
treatment of patients with MGD, in which there was a signifi-
cant improvement of symptoms and signs in both groups. There
was, however, no significant difference in improvement of
patients’ symptoms between the two groups at the last follow-up
visit (table 3). Although the last follow-up mean score of all
clinical signs was better in the azithromycin group, a statistically
significant difference was only observed for conjunctival redness
and ocular surface staining (table 4). In general, the percentage
of clinical improvement was significantly better in the azithro-
mycin group at the last follow-up.
While the pathogenesis of MGD is still unclear and complex,
both inflammation and bacterial colonisation are, to a different
extent, playing a role.14 19
Although conservative management
may be effective in the management of MGD, oral antibiotic/
anti-inflammatory treatment is suggested when the improvement
is slow or incomplete.12
More than normal colonisation of dif-
ferent bacteria synthesise lipolytic enzymes which produce irri-
tating fatty acids and cholesterol to create tear film instability
and inflammation.12
It is believed that some antibiotics with
anti-inflammatory effects may help to control the bacterial col-
onisation and also eyelid inflammation.7 12 14 16 20
Although the role of doxycycline in the treatment of MGD
has been shown previously,21
its side effects and subsequently
low compliance of the patients sometimes result in treatment
abortion. Its side effects include dermatological effects (macula,
papules), gastrointestinal effects (oesophagitis, dyspepsia, diar-
rhoea, vomiting), and hypersensitivity (allergy, urticaria).20
However, this study showed a few gastrointestinal side effects in
the doxycycline group. They were reported by 15 patients
(30%) in the first week after starting the doxycycline, decreased
to 26% (13/50) at the end of the 1-month treatment course,
and then to 14% (7/50) at the end of the study.
Azithromycin has also been recently introduced; used in either
its topical14 16
or oral12 22
forms it has been found to be effective
in the treatment of MGD. Azithromycin is a semisynthetic macro-
lide antibiotic with a good intracellular penetration and long half-
life; it has an anti-inflammatory and immunomodulatory effect
that could help reduce eyelid and ocular surface inflammation.12
The oral formulation of azithromycin can suppress the produc-
tion of some pro-inflammatory mediators like cytokines (TNFα,
IL-1β), chemokines and metalloproteinases (MMP-1, MMP-3 and
MMP-9).22
Its antibacterial and anti-inflammatory effects,
coupled with a long half-life, make oral azithromycin a good
treatment option for MGD.12
Results of this randomised clinical
trial support the results of a recent publication on the beneficial
effects of oral azithromycin on symptoms and signs of patients
with posterior blepharitis.12
Such an effect has also been reported
using topical azithromycin.16
The better effect of azithromycin
on the symptoms and signs (table 3) in this trial could be attribu-
ted to a better antibacterial effect, inhibition of bacterial lipases
and degradation of meibomian gland lipid, and/or its anti-
inflammatory effects. However, we could not account for the fact
that a significantly better improvement was observed in conjunc-
tival redness and ocular surface staining (table 4).
Bakar et al23
reported that the side effects of systemic azithro-
mycin were minimal and well tolerated in most patients treated
for populo-pustular rosacea. Likewise, this series showed mild
and temporary side effects which did not require treatment to
be discontinued. The most common side effect was decreased
appetite, which has also been reported by Greene et al.22
We,
however, could not account for why three of the azithromycin
Table 2 Demographics of 100 patients with meibomian gland
dysfunction who were treated with either oral azithromycin or oral
doxycycline
Azithromycin
(50)
Doxycycline
(50) p Value
Male/female 24/26 26/24 0.8
Mean (SD) of age (years) 42 (16.3) 38.5 (14.6) 0.2
Mean (SD) duration of disease
(weeks)
14.2 (11.9) 10.3 (7.3) 0.057
Chief complaint
Itching 10 (20%) 8 (16%) 0.3
Foreign body sensation 13 (26%) 11 (22%)
Dryness 17 (34%) 13 (26%)
Burning 9 (18%) 12 (24%)
Lid swelling 1 (2%) 6 (12%)
Systemic diseases
None 26 (52%) 4 (8%) 0.6
Diabetes mellitus 8 (16%) 2 (4%)
Chronic anaemia 2 (4%) 3 (6%)
Ischaemic heart disease 5 (10%) 2 (4%)
Asthma 2 (4%) 12 (24%)
Gastrointestinal 7 (14%) 4 (8%)
Figure 2 Four-point categorical scale panel for grading ocular surface
staining.
4 Kashkouli MB, et al. Br J Ophthalmol 2014;0:1–6. doi:10.1136/bjophthalmol-2014-305410
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5. patients still had decreased appetite 7 weeks after stopping the
medication (table 5).
The cost of 1-month treatment with doxycycline is almost
50% more than 5-day treatment with oral azithromycin in our
country. Since MGD is a chronic disease, multiple 5-day pulse
treatment with azithromycin would be cheaper than long term
daily oral doxycycline.
Strengths of this study were its randomised masked trial
design, using a grading system to quantify the qualitative mea-
sures, and maintaining the conservative management of the
MGD in both groups. One limitation might be the absence of a
control group without any systemic medication; there has been
debate24
on whether clinical trials essentially require a placebo
control instead of having an active treatment control. However,
Table 4 Mean score (SD) of seven signs before and at the last follow-up visit in 100 patients with meibomian gland dysfunction who were
treated with either oral doxycycline or azithromycin
Meibomian gland
secretion
Meibomian gland
plugging
Bulbar conjunctival
redness
Eyelid margin
redness
Eyelid margin
debris
Tear break-up
time
Ocular surface
staining
Doxycycline
(pretreatment)
1.7 (0.6) 1.9 (0.5) 1.5 (0.7) 1.9 (0.7) 1.2 (0.8) 1.3 (0.7) 1.5 (0.6)
Azithromycin
(pretreatment)
1.5 (0.6) 1.9 (0.6) 1.6 (0.7) 1.7 (0.7) 1.1 (0.8) 1.1 (0.8) 1.4 (0.7)
p Value 0.08 0.9 0.4 0.1 0.6 0.1 0.1
Doxycycline (last
follow-up)
1 (0.6) 1 (0.6) 1 (0.6) 1.1 (0.8) 0.7 (0.8) 0.7 (0.6) 0.8 (0.8)
Azithromycin (last
follow-up)
0.8 (0.7) 0.8 (0.7) 0.6 (0.6) 0.8 (0.8) 0.6 (0.7) 0.5 (0.6) 0.4 (0.7)
p Value 0.2 0.2 0.004 0.1 0.3 0.058 0.01
Lower scores show less severity.
Table 5 Comparison of side effects in the azithromycin and doxycycline treatment groups at different follow-up visits
Nausea Abdominal cramp Diarrhoea Decreased appetite p Value
1st visit
Azithromycin 6 (12%) 5 (10%) 1 (2%) 9 (18%) 0.24
Doxycycline 10 (20%) 8 (16%) 0 13 (26%)
2nd visit
Azithromycin 2 (4%) 1 (2%) 0 2 (4%) 0.002
Doxycycline 7 (14%) 6 (12%) 0 9 (18%)
3rd visit
Azithromycin 0 0 0 3 (6%) 0.11
Doxycycline 2 (4%) 2 (4%) 1 (2%) 7 (14%)
Table 3 Mean symptom, sign and total scores (SD) of 100 patients with meibomian gland dysfunction at four clinical visits
Azithromycin group (50 patients) Doxycycline group (50 patients) p Value 95% CI
Pretreatment
Symptom 7.2 (2.3) 6.8 (2) 0.3 −0.4 to 1.2
Sign 10.6 (2.7) 11.3 (2.2) 0.1 −1.7 to 0.2
Total 17.8 (4.5) 18.2 (3.8) 0.6 −2 to 1.2
First follow-up
Symptom 5.5 (2.2) 5.7 (2) 0.6 −1 to 0.6
Sign 7.9 (2.8) 8.5 (2.4) 0.2 −1.7 to 0.3
Total 13.4 (4.5) 14.2 (4) 0.3 −2.5 to 0.8
Second follow-up
Symptom 4.8 (2.1) 5 (1.7) 0.6 −0.9 to 0.5
Sign 6.4 (2.6) 7.6 (2.3) 0.01 −2.2 to −0.2
Total 11.3 (4) 12.9 (3.2) 0.02 −3 to −0.1
Last follow-up
Symptom 4.3 (2.2) 5 (2.1) 0.1 −1.5 to 0.2
Sign 4.8 (2.5) 6.7 (2.5) <0.001 −2.8 to −0.8
Total 9.1 (4.1) 11.7 (4) 0.002 −4.2 to −0.9
Lower scores show less severity.
Kashkouli MB, et al. Br J Ophthalmol 2014;0:1–6. doi:10.1136/bjophthalmol-2014-305410 5
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6. since enrolled patients had not responded to conservative man-
agement and had moderate to severe MGD (two signs and two
symptoms of at least grade 2 severity, of which one had to be
meibomian gland signs), systemic medication (doxycycline or
azithromycin) was deemed to be required. Another limitation
would be considering all signs (meibomian gland, eyelid and
ocular surface signs) with the same value in calculation and ana-
lysis of the mean sign score. To overcome such a limitation, a
separate analysis was also performed to evaluate the change in
each sign (table 4) after different treatments. Using one dosing
regimen of oral azithromycin and doxycycline and not consider-
ing topical azithromycin is another limitation, which future
studies are recommended to address.
In conclusion, this randomised double masked open label
clinical trial demonstrated beneficial effects for both oral doxy-
cycline and azithromycin in patients with MGD. The azithromy-
cin group, however, had a relatively better effect with regard to
symptom (statistically insignificant) and sign (statistically signifi-
cant) scores and fewer side effects. Therefore, a 5-day course of
oral azithromycin is recommended based on better clinical
improvement, shorter duration of treatment, lower cost and less
side effects. Since MGD is a chronic disease, a longer term
regime (repeating the 5-day treatment course) would be often
required.
Future studies are recommended to assess different doses of
oral azithromycin, topical versus oral azithromycin, and the
number and time interval of oral azithromycin courses in
patients with MGD.
Contributors Conception or design of the work (MBK), the acquisition, analysis or
interpretation of data (AJF, VK, MN, LG), drafting the work or revising it critically for
important intellectual content (MBK, LG), and final approval of the version published
(MBK). All agreed to be accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Funding This study was financially supported by the Eye Research Center, Iran
University of Medical Sciences.
Competing interests None.
Ethics approval Tehran University of Medical Sciences ethic committee (no.
90-01-124-13076).
Provenance and peer review Not commissioned; externally peer reviewed.
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Clinical science
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7. doi: 10.1136/bjophthalmol-2014-305410
published online August 19, 2014
Br J Ophthalmol
Mohsen Bahmani Kashkouli, Ali Jalili Fazel, Victoria Kiavash, et al.
clinical trial
randomised double masked open label
meibomian gland dysfunction: a
Oral azithromycin versus doxycycline in
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