EyeWorld Asia-Pacific September 2016 Issue

58 EWAP cornea September 2016 Oral antibiotics to treat meibomian gland-related ocular surface disease lacking in data Authors advocate for future prospective clinical trials, but others question if that’s necessary for a treatment with “historic benefit” M eibomian gland dysfunction (MGD) is considered one of the most common conditions seen by ophthalmologists and is labeled as one of the most common causes of evaporative dry eye. 1 A common treatment ophthalmologists recommend when they diagnose a patient with a meibomian gland-related ocular surface disease is antibiotics like doxycycline, minocycline, and azithromycin. But are these antibiotics really improving the signs and symptoms of this condition? That’s what Edward “Ted” Wladis, MD , Lions Eye Institute, Slingerlands, New York, et al. sought to answer in an Ophthalmic Technology Assessment prepared by the American Academy of Ophthalmology. The findings from this literature review and meta-analysis were published in the March 2016 issue of Ophthalmology . 2 In general, Dr. Wladis said he and his fellow authors were surprised at how little published research there is regarding MGD- related ocular surface disease and antibiotics. “I think the big issue is that this is such a common disease,” Dr. Wladis said. “So many of our patients come in and they really do suffer from it, but unfortunately it’s a disease that is very frustrating, both for the patient and the clinician. We don’t have great answers for it. We felt it would be important to quantify the effects that antibiotics have for the disease. “What we were hoping for was some mechanism by which we could determine whether or not oral antibiotics make a difference in the disease, and therefore try to give our patients some degree of certainty that this relatively common practice will make a difference for them,” he continued. The study authors identified 87 articles that fit their criteria in a literature search, narrowing it down to eight studies for the final analysis. None of these included research that was considered “well- conducted randomized controlled trials” classified as level I evidence by the study authors. Instead, the papers identified were level II (“well-conducted case-control or cohort studies, as well as lower- quality randomized controlled trials”) and level III (case series and lower-quality case-control and cohort studies) evidence studies. Of the studies that were analyzed, Dr. Wladis said they showed a “nice benefit” for the use of these antibiotics, which are known to both kill the bacteria that could be causing an immune response and also produce an anti-inflammatory effect that could relieve some of the symptoms of MGD. “[These studies] weren’t the ‘gold standard,’ level I evidence that we’d like to be able to cite when we give our patients such a relatively invasive intervention,” Dr. Wladis said, expressing surprise that more studies like this have not been done given how common the disease is. “While some of the studies were certainly promising, there was no slam dunk where we can tell our patients with absolute certainty that oral antibiotics make a huge difference in the management of meibomian gland disease.” In order to reach that goal, Dr. Wladis and the coauthors advocate in the study for a randomized, controlled trial using standardized grading systems and a standardized dosing schedule to assess the efficacy of antibiotics for MGD-related ocular surface diseases. This, Dr. Wladis said, would allow ophthalmologists to “say with absolute certainty whether or not these antibiotics do work effectively.” But is that really necessary? Edward Holland, MD , Cincinnati Eye Institute, Cincinnati, said that while he agrees with the study authors’ conclusion that there isn’t a lot of data in terms of a prospective trial that documents the use of these antibiotics for MGD, he doesn’t think one is necessary. “There isn’t good, long-term, prospective clinical trial [data], and part of the reason is when this was initially used in ophthalmology, we borrowed the treatments from our colleagues in dermatology who have done good studies,” Dr. Holland said. “Some things in medicine have a historic validation in terms of treatment efficacy. I’ve been treating MGD for 30 years, and I strongly believe that oral antibiotics in the macrolide class are an important and efficacious treatment for this disorder and have saved a countless number of patients’ vision,” Dr. Holland continued. Hank Perry, MD , Ophthalmic Consultants of Long Island, Rockville Centre, New York, also said he thinks the use of oral antibiotics for this condition is well-known and established enough to not merit a need for a prospective study. Dr. Holland said that while the antibiotics are inexpensive, research funding is hard to come by, and he doesn’t think a company making these products will pay for the research, as it would be unlikely they’d recoup their money. Dr. Holland also questioned why some of the methodology for identifying articles for the meta- analysis included key words that were unrelated to MGD-related ocular surface disease. When asked about this, Dr. Wladis said he and his coauthors included seemingly unrelated search terms to cast a wide net and allow for closer scrutiny to make sure nothing was by Liz Hillman EyeWorld Staff Writer