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Doxycycline is a commonly used drug among optometrists. It is the drug of choice of the tetracyclines. Doxycycline comes in an easier dosage, has less side effects than tetracylcline proper, is inexpensive, and can generally be taken with little regard to meals or dairy products. Patients, however, should still be cautioned to take the medication at breakfast and supper to lessen the possibility of GI upset. Patients taking Doxycycline sunburn more easily, so should also be cautioned to use sunscreen when outdoors.
Doxycycline is a Category D drug and, therefore, should not be prescribed to pregnant or nursing women. It should not be given to children because of the discoloration of teeth that can occur.
The Tetracyclines
Tetracyclines are best utilized in the optometric practice for treating long-term issues as opposed to acute. Examples would include:
- Meibomian gland dysfunction (MGD)
- posterior blepharitis
- acne rosacea
- Phlyctenular keratoconjunctivitis (secondary to staph hypersensitivity)
Dr. Grogg usually sees phlyctenular keratoconjunctivitis in those contact lens wearers who are using generic contact lens solutions, who have tight contact lens fits, or who are non-compliant with their contact lens wearing schedules. It is written, however, that phlyctenules are commonly caused by staph hypersensitivity, so you may have a patient with phlyctenular keratoconjunctivitis who does not wear contact lenses or who does not have allergies. Tetracyclines can be used to treat these patients as well.
- Recurrent erosions
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Old treatment for chlamydia/Reiter's syndrome
There is an increased risk of pseudotumor cerebri (PTC) with this medication because it is lipophylic and crosses the blood-brain barrier.
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Symptoms of meibomianitis (also known as posterior blepharitis, ocular rosacea) include chronic burning, irritation, and redness--which Dr. Grogg likes to call the chronic "itchie-burnies." Signs include MGD, chronic conjunctivitis, acne rosacea, telangectatic vessels, tylosis, and pannus. With typical acne rosacea, men are not as likely to seek treatment for cosmetic reasons, so you may be the first doctor they've seen.
Some patients have increased ocular symptoms but not a lot of facial signs of rosacea. There may not be a lot of rosacea appearance on face, but they have a lot of meibomian gland dysfunction.
When you're looking for MGD, it is sometimes as simple as "soapsuds" in the tear film.
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Posterior blepharitis: Push on the meibomian glands to see what comes out. What is worst case scenario when pushing on the meibomian glands? Nothing comes out! If you get fine, cheesy secretions--you still have a moderate form of MGD. Nothing indicates that the glands have completely shut down.
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This is the sort of thing we are trying to prevent . . . the complications we are hoping to avoid.
Corneas can become really beat up. Peripheral corneal thinning, neovascularization, and pannus occur--creating a chronically uncomfortable eye. This can affect the refractive error as well. |
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Example of "soapsuds"--that in itself is indication of MGD. So, at the very least, this person needs warm compresses and lid massage.
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Dosage for Rosacea and MGD
Dosage varies depending upon the severity of the case. Prescribe 100 mg of Doxycycline twice a day for a minimum of 10 days to 2 weeks and up to 3 months in very severe cases. Taper to 100 mg qd x 3-6 months. Consider further taper to 50 mg qd. When tapering 50 mg once daily, have the patient call if he/she feels there is an increase in symptoms or feels the medication is no longer working.
Oracea 40 mg, a relatively new drug, is available for treatment as well. Oracea is 30 mg of Doxycycline plus 10 mg of extended-release Doxycycline. It is expensive: $175 for 30 days (vs. $15 for Doxycycline).
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Conjunctivitis Association
Patients often present acutely. They're miserable with their eyes. Many can tolerate the telangictation, rhinophyma, and acne, but come in when their eye is red and irritated. Hypersensitivity is big component to MGD. Antibiotics will go a long way, but steroids will take out the punch. If the patient has infiltrative keratitis, he/she especially needs an antibiotic/steroid combination to hasten comfort.
A steroid combination to use can be either Tobradex or Blephamide.
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LEFT: Examples of staph-related margin keratitis. Notice the clear zone between the limbus and the ulcer. This is common in staph-related ulcers. A conservative approach would be an appropriate topical antibiotic for 24 hours, then a topical steroid added the next day. Dr. Grogg commonly uses an antibiotic-steroid combination very effectively the first day. Decreasing the inflammation will actually help the epithelium heal. |
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