FEB 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 60 of 114

E W FEATURE 58 days in three cycles with seven-day intervals were implemented. "Other smaller studies have been mentioned in some of the peer review as well," Dr. Tauber said. "But there's been no standardization in the treatment dosing, so it remains unknown what the best course may b e." Current treatment strategies In treating patients who have been unsuccessfully managed previously, "if they have failed topical azithromycin therapy, I will move to more intense lid expression, contin- u ed doxycycline use, topical cy- closporine, and possible LipiFlow therapy," Dr. Foulks said, noting he has not yet used oral azithromycin in refractory patients. Dr. Tauber said when patients are referred to him who have not achieved the comfort they need, "you have to go back to the begin- ning and start over. Lid hygiene is downright essential." He recom- mends using a gel mask that can be microwaved to make it easier to a chieve heated lid expression. Dr. McCulley is an advocate of both doxycycline and minocycline (in Texas, many of his dermatologist colleagues prefer minocycline over doxycycline, so he tends to prescribe the former more often). "People who prefer using doxy- cycline cite that minocycline may cause tinnitus in some patients," he s aid, but added studies have shown minocycline "penetrates the tissue much better than we anticipated, well enough to eradicate Staphylococ- cus aureus." 4 Dermatologists cite the tetracycline derivative's therapeutic benefit in acne rosacea as well, he said. "Doxycycline has been used for more than 30 years," Dr. Margolis said. "Some patients respond, some don't. Clinicians need to ask what their ultimate end point is—do you want your patients to have 'less red' or do you want them to walk out of your offices feeling better? My focus has always been on comfort." Any of the oral tetracyclines have "justifiably earned a place in the treatment of meibomitis, MGD, and rosacea," Dr. Foulks said. "We demonstrated improvement in the character of the lipid secretion with oral doxycycline, but it took longer than topical azithromycin and resulted in different changes in the lipid than occur with topical azithromycin." 5 When clinicians are treating lid disease and patients feel better, Dr. Lemp cautions the ocular surface may still be unhealthy and to be vigilant in treating any surface disorders as well. Dr. Margolis said he advocates ascertaining the "real problem" for these patients. "Horrible pain post-LASIK is not the same as a chronic surface or lid disorder that's causing pain," he said. "If there's some degree of MGD and the patient complains of pain, we'll likely start them on steroids, follow for about four weeks and re-evaluate, with the caveat that if the patient experiences any side effects to stop treatment and come in immediately." Doxycycline can lead to yeast infections and upset stomach in ad- dition to skin disorders; Dr. Margolis has not seen the same types of reac- tions with oral azithromycin. He dis- agrees with intensifying lid hygiene, however. "The more you manipulate the l ids, the more you're going to irritate them," he said. "I take a more mini- malist approach and recommend the patient rub a little steroid into the lids at the outer edges only once or twice a day." Patients seem to appreciate that they are applying a mild steroid to the lid margins only, Dr. Margolis said. Dr. Jeng said while results of the c urrent analysis are far from perfect, "what I'm hoping is that people will start thinking about oral azithromycin. And maybe that can lead to a prospective trial on the treatment." EW References 1. Nelson JD, Shimazaki J, Benitez-del- Castillo J, et al. The International Workshop on Meibomian Gland Dysfunction: Report of the Definition and Classification Subcommittee. Invest Ophthalmol Vis Sci. 2011;52(4): 1930– 1937. 2. Greene JB, Jeng BH, Fintelmann RE, Margolis TP. Oral azithromycin for the treat- ment of meibomitis. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2013.5295 Published online Nov. 7, 2013. 3. Igami TZ, Holzchuh R, Osaki TH, Santo RM, Kara-Jose N, Hida RY. Oral azithromycin for treatment of posterior blepharitis. Cornea. 2011;30(10):1145-9. 4. Ta CN, Shine WE, McCulley JP, Pandya A, Trattler W, Norbury JW. Effects of minocycline on the ocular flora of patients with acne rosacea or seborrheic blepharitis. Cornea. 2003;22:545-548. 5. Foulks GN, Borchman D, Yappert M, Kakar S. Topical Azithromycin and Oral Doxycycline Therapy of Meibomian Gland Dysfunction: A comparative clinical and spectroscopic pilot study. Cornea. 2013;32:44-53. Editors' note: The physicians have no financial interests directly related to their comments, although they have all conducted research on the topic. Contact information Foulks: foulksgary@gmail.com Jeng: bjeng@som.umaryland.edu Lemp: malemp@lempdc.com Margolis: todd.margolis@ucsf.edu McCulley: james.mcculley@utsouthwestern.edu Tauber: jt@taubereye.com February 2011 Corneal infections February 2014 Treating continued from page 57 Muraine Punch • Minimizes loss of donor corneas during graft creation • Faster than alternative techniques • Excellent cell viability Corneal Transplant C n r o eal T s n a r plant Muraine Punch t uraine Punch Muraine Punch uraine Punch • Minimizes loss of donor co during graft c rneas during graft creation s of donor co • Faster than alte • Excellent cell viability • Faster than alternative techniques • Excellent cell viability US : Patent Pending. h T fr P m o r r u M . M . i a e n and h s i de i v e c s i ma f u n a u t c red and so d l w r o d i w d l e y b o M d n U v i r e i s ty Ho i p s t l a r F , n e u o R f o a e c n . r o a i n u d r e a c x e n lu v i s e i l n e c se 56-68 Feature_EW February 2014-DL2_Layout 1 1/30/14 10:44 AM Page 58

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