Should you take antibiotics with that bump on your eyelid?


Eyelid bumps, sometimes called styes, are very common. They are usually red, sometimes painful, and sometimes will stay there for months. Sometimes these bumps keep coming back. There are two major types of eyelid bumps, one called hordeolum and the other chalazion. Both are caused by blocked oil glands in the eyelid, called meibomian glands. This gland secretes oil through an opening on the eyelid margin (that’s the thin edge at the base of the eye lashes). This oil is really important to keep our tears in good quality (refer to some of my previous posts on meibomian gland and dry eye). When the opening is blocked, the oil backs up inside the gland, and forms a bump. In terms of the hordeolum, this oil content is infected by our normal skin bacterial flora, so this is technically an infection, but it’s often self-limited. In terms of the chalazion, this content undergoes an inflammatory process but not infection. This is one of the reasons that the hordeolum is often painful and chalazion is not.

Regardless, given similar etiology, the treatment is to open up the blocked gland and let the oil flow again. And one effective way to do this is to apply a warm compress on the bump, this allows the content to soften and drain more easily.

However, doctors sometimes prescribe antibiotics, be it an oral pill, or an eye drop or ointment. So the question is: is it necessary to take antibiotics for hordeolum or chalazion?

There is a recent research [1] that retrospectively looked at more than 2,712 cases of these two conditions, some of these were treated with warm compress alone, some with antibiotics alone, and some with warm compress as well as antibiotics. The final outcome shows that all 3 treatments led to a similar rate of resolution, over 70% for chalazion and over 90% for hordeolum. This shows that additional topic antibiotic drops/ointment or oral antibiotics do not really give additional benefit. Warm compress alone works just as well. It’s interesting that antibiotics alone also have a good success rate, though only 1% of patients were treated by this method. 

The limitation is that this is a retrospective study. There is a randomized controlled trial looking at chalazion and found similar outcome: antibiotics do not give additional benefit in addition to warm compress [2].

Given the rampant antibiotic resistance these days, I think it’s reasonable to apply just warm compress and not start antibiotics automatically for every eyelid bump.

References: 

[1] Alsoudi, Amer F. B.S.; Ton, Lauren B.S.; Ashraf, Davin C. M.D.; Idowu, Oluwatobi O. M.D.; Kong, Alan W. B.S.; Wang, Linyan M.D.; Kersten, Robert C. M.D.; Winn, Bryan J. M.D.; Grob, Seanna R. M.D.; Vagefi, M. Reza M.D. Efficacy of Care and Antibiotic Use for Chalazia and Hordeola, Eye & Contact Lens: Science & Clinical Practice: November 8, 2021 – Volume – Issue – doi: 10.1097/ICL.0000000000000859

[2] Wu AY, Gervasio KA, Gergoudis KN, Wei C, Oestreicher JH, Harvey JT. Conservative therapy for chalazia: is it really effective? Acta Ophthalmol. 2018 Jun;96(4):e503-e509. doi: 10.1111/aos.13675. Epub 2018 Jan 16. PMID: 29338124; PMCID: PMC6047938.

Normative database of axial length in children

This article is for eye doctors who use axial length routinely in their myopia control clinic, and certain parents who are curious and/or obsessed with the numbers of their children’s eyes (trust me, I do encounter these parents weekly).

Briefly, axial length is the length of the eyeball, which grows throughout the first 18 years of a person’s life. It is normal for the eyes to grow longer over time until it stabilizes at adulthood. But the growth can be accelerated resulting in long axial length in myopia. Therefore in many eye doctors’ offices, this value is measured to monitor myopia development and record whether myopia control is successful with a given intervention.

Understandably, it is important to have a normative database to evaluate whether a given child’s axial length is normal. Basically, there have been quite a few published articles on typical axial lengths of children of various ages. I have put together data from two recent studies that encompass ages from 3 months to 18 years below. The mean values for a given age are listed, as well as standard deviation. Table 1 is from Florida, USA, on 165 American children (Miami study) [1] and table 2 is from Shanghai, China, on 14,127 Chinese children (Shanghai study) [2]. Obviously the 2nd study is a much larger scale, and I really am very excited about this very new data. The first study, though with much fewer subjects, is quite remarkable as well in my opinion, as it examined kids as early as 3 months, understandably not easy to do and not many other studies were able to look at this age group. So I am keeping these two tables as a reference for my own patients. 

For those who are more visual, Figure 1 and Figure 2 are these numbers plotted in graphs.

Table 1. Axial length of 3 month to 7 years old children (Miami study)

Table 2. Axial length of 4 to 18 years old children (Shanghai study)

Figure 1. Axial length mean (solid line) and 95% confidence interval (dotted lines) in 3 month to 7 years old children (Miami study).

Figure 2. Axial length ranges in 4 to 18 years old children (Shanghai study).

A few things to keep in mind from these data. 

First, these are from two distinct populations. The 3 month to 7 years old study group (Miami study) were children from Miami, FL. No ethnic background information was given in the paper, but one can assume it could be typical from that area. The 4 to 18 years old study group (2nd Shanghai study) were Chinese children. It is well known that Chinese children have longer axial lengths than Caucasions and African descents (and more prevalent myopia rates unfortunately), so we certainly cannot assume that this is inclusive of all possible scenarios. 

Second, you can see that for any given age, there is a wide range of axial lengths in both studies. This tells us that normal is a range, NOT a single number. Do NOT compare the number of your child to your neighbor’s kids. This is not a competition. Also, it has been demonstrated again and again that it is the rate of axial length growth, rather than the absolute number, that better predicts myopia progression. Do not get anxious over one measurement. Monitor the axial length over time to find the trend. 

Lastly, I would still stress that while it is great that we have a normative database for axial length, it is still the gold standard to perform cycloplegic refraction to accurately assess a child’s true refractive error. Axial length measurement is a powerful tool, but it does not and cannot replace cycloplegic refraction.

References:

[1] Miami study: Bach A, Villegas VM, Gold AS, Shi W, Murray TG. Axial length development in children. Int J Ophthalmol. 2019;12(5):815-819. Published 2019 May 18. doi:10.18240/ijo.2019.05.18

[2] Shanghai study: He X, Sankaridurg P, Naduvilath T, Wang J, Xiong S, Weng R, Du L, Chen J, Zou H, Xu X. Normative data and percentile curves for axial length and axial length/corneal curvature in Chinese children and adolescents aged 4-18 years. Br J Ophthalmol. 2021 Sep 16:bjophthalmol-2021-319431. doi: 10.1136/bjophthalmol-2021-319431. Epub ahead of print. PMID: 34531198.

新冠疫情下的儿童近视讲座(Myopia Control in COVID-19; Language: Mandarin)

Please join us for a scheduled Zoom meeting.

Topic: 新冠疫情下的儿童近视讲座(Myopia Control in COVID-19; Language: Mandarin)
Time: May 23, 2020 08:00 PM Eastern Time (US and Canada)
Speaker: Dr. Yueran Yan
Meeting Capacity: 100 (first come, first served)

Join Zoom Meeting
https://us04web.zoom.us/j/73089566870?pwd=ZTlnQkY3QUVId002d0p3cTJWcUdsUT09

Meeting ID: 730 8956 6870
Password: 6qC3i8

FDA approves new OTC allergy eye drops

Allergy season is coming. Millions of Americans will suffer from itchy and watery eyes shortly. The current treatment of itchy eyes can be done by only two types of OTC products, one is ketotifen- based, such as zaditor or allaway. Ketotifen has anti-histamine as well as mast cell stabilizer activity, and works generally well for itchy eyes. The other type is pheniramine- based, such as Visine-A and Opcon-A. This one only has anti-histamine activity. In addition, Visine-A contains a vasoconstrictor, which may temporarily relieves redness but over long-term may cause worsening red eyes.

For many patients, ketotifen may not be enough to relieve their itchiness. In such cases I often prescribe patanol or pataday (olopatadine 0.1% and 0.2% respectively). These usually work very well, and quite safe and well- tolerated, though patients have to come to see a doctor to get prescription.

Now FDA just approved patanol and pataday as OTC, and may be available as early as March 2, 2020. (news link https://www.mdmag.com/medical-news/pataday-fda-approves-prescription-allergy-eye-drops-over-the-counter-alcon)

This is great news. As patients no longer have to wait for weeks before getting an appointment from an eye doctor’s office. If your eyes are itchy, just go to the pharmacy to pick up some ketotifen or patanol if the former does not work for you. This will also reduce cost from health care system and reduce work productivity lost due to going to doctors’ offices. Of course I bet it will be expensive, but having easy access is the key point here. And hopefully generics become available in future to make it more affordable for consumers.

Seeing a bluish green spot in the right eye

By Juan Ding, OD, PhD

Case of the day series

A college student walked in for an urgent visit for seeing a bluish green spot in her right eye constantly for 1 week. She went to Colorado last week and did a lot of hiking, taking many photos everyday, enjoying nature. On the last day of the trip, she started seeing a bluish green spot in the right eye, more obvious in the bright background, but it’s there even after closing eyes. She was very scared and went to the local ER, where they did an ultrasound of the eye and found no retinal detachment, but did not know what’s wrong. After getting back to MA, she could not get an appointment with her regular eye doctor, and being the holiday season it’s busy everywhere. Fortunately her PCP at Umass directed her to our open access clinic.

Her vision is normal, 20/20 in each eye. Everything from the front to the back of both eyes are normal. I found no retinal detachment, not even vitreous floaters.

She asked, “Am I crazy? Am I imagining things?”

What do you do next?

Knowing too well that clinical exam has its limitations, I asked her to take an OCT photo. This is looking at the retina in cross sections, like virtually dissection the retina. There is a very small dot in the right eye, just temporal to the fovea, where the photoreceptor outer segment now shows a small defect (Figure 1). Amsler grid shows a matching scotoma nasal to the fixation.

solar retinopathy

Figure 1. OCT of macula cross section. Red arrow points to the lesion at the photoreceptor outer segment level (ellipsoid zone).

 

So I told her that she’s not crazy, a retinal lesion really exists to perfectly account for her seeing the spot.

But what caused it?

Solar retinopathy is the first thing that comes to mind. She denied looking directly at the sun. also denied exposure to laser including laser pen or in a science project. Then she mentioned that during daily hiking, she did spend a lot of time looking at camera screen which could be very bright due to reflecting sunlight. This seems to be the most plausible explanation for now.

I told her that solar retinopathy may get well on its own in weeks to months. It may also be irreversible. At any rate, there is no treatment for this. So we will monitor again in a few months.

Another treatment for dry eye – azithromycin

by Juan Ding, OD, PhD

I talked earlier about an off label treatment of dry eye and Meibomian gland dysfunction (MGD), doxycycline; and today I will talk about another off label use of azithromycin (AZM) to treat MGD.

AZM is a macrolide type of antibiotic that has a unique characteristic, to promote lipid accumulation in cells. This works well in MGD, because the Meibomian gland cells work by producing and storing lipid and then releasing it to the tear film. With this additional help, my coworkers and I found that the Meibomian gland cells produce more fat 1. And these effects are unique as doxycycline and other tetracyclines do not have this benefit 2. Other scientists found that AZM significant improves dry eye symptoms and work slightly better than doxycycline 3. Further, the dosage and usage is easier with AZM, which is used for 500 mg on the first day and then 250 mg/day for a further 4 days, whereas doxycycline was used for 100 mg twice a day for 7 days and then 100 mg/day for a further 21 days 3.

AZM also exists in an eye drop format, for example, azasite (1% AZM ophthalmic solution). This also works well for MGD and dry eye, though it’s quite expensive and sometimes not covered by insurance.

Side effects of AZM include diarrhea or loose stools, nausea, abdominal pain, stomach upset, vomiting, constipation, dizziness, etc. it is safe to use during pregnancy and breastfeeding.

I prefer the AZM eye drop, which works more targeted to the ocular surface without systemic side effect. Due to its cost, I typically use it only in patients with MGD and blepharitis (inflammation of the eyelid margin) that have failed other treatments. I have had some very grateful patients who report they can finally open their eyes or that their eyes are no longer constantly red. The usage of this of course requires a prescription and supervision under a qualified physician.

I wish they make this cheaper and make an ointment form of this.

References:

 

  1. Liu Y, Kam WR, Ding J, Sullivan DA. Effect of azithromycin on lipid accumulation in immortalized human meibomian gland epithelial cells. JAMA Ophthalmol. Feb 2014;132(2):226-228.
  2. Liu Y, Kam WR, Ding J, Sullivan DA. Can tetracycline antibiotics duplicate the ability of azithromycin to stimulate human meibomian gland epithelial cell differentiation? Cornea. Mar 2015;34(3):342-346.
  3. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J. Ophthalmol. Apr 2019;67(4):464-471.

 

Another treatment for dry eye – doxycycline

The other day a 57 year old woman came in, with a very common complaint, dry eye.

She had dry eye symptoms for a few years previously. Last year, due to Lyme’s disease (infection by Borrelia bacterium which is spread by ticks), her doctor prescribed doxycycline for 14 days. After that, she enjoyed dry-eye free days for almost 8 months, until now when the symptoms are back to haunt her. She tried a few artificial tears which helped only a few minutes. She would really like to have another prescription of doxycycline.

On examination, she has Meibomian gland dysfunction (MGD; here’s my previous article on MGD) and dilated blood vessels on the lid margin suspicious for ocular rosacea. She’s never been diagnosed with rosacea before and denies cheeks turning red.

We know that MGD is a major cause of dry eye, and ocular rosacea (a type of inflammation of the eyelids) will make dry eye worse. In fact, doxycycline has been used off-label to treat MGD and ocular rosacea. In one study, for MGD patients treated with doxycycline for 30 days, about 70% of patients showed some level of improvement after one or multiple (up to three times) treatments 1.

Therefore, for certain patients who failed conventional warm compress and lid hygiene treatment for MGD, it may be worthwhile to try doxycycline

Of course, doxycycline has several side effects, and should be taken with some caution. Many of the side effects are related to the gastrointestinal health, such as loss of appetite, nausea and vomiting, diarrhea. People may also get sensitivity to the sun, so sun protection while using this medication is recommended. Lastly it may also cause discoloring of teeth, while reversible in adults, may be permanent in kids, so it should not be used in children younger than 8 years of age. Fortunately not too many 8 year olds have MGD or dry eye. Doxycycline also should not be used during pregnancy.

Next time I will talk about an even better alternative drug for MGD. If you read the reference below, you will guess what it is.

 

References

  1. De Benedetti G, Vaiano AS. Oral azithromycin and oral doxycycline for the treatment of Meibomian gland dysfunction: A 9-month comparative case series. Indian J. Ophthalmol. 2019;67(4):464-471.