Prescribed Medicines for Dry Eye: Steroids, Doxycycline and Azithromycin

Most dry eye is managed without a prescription: lid hygiene, heat, lubricants matched to the tear deficiency, and where indicated an in-clinic procedure. But dry eye is fundamentally an inflammatory disease, and there is a point at which inflammation has to be treated directly rather than lubricated around. That is where prescribed medicines come in.

New Zealand optometrists with therapeutic endorsement prescribe these medicines routinely, and every Dry Eye Specialist Group member practice works within that scope. This article explains what each medicine is for — not so you can self-prescribe, but so the conversation in the consulting room makes sense.

Topical corticosteroids: fluorometholone and dexamethasone

Steroid eye drops are the most direct anti-inflammatory tool available. Fluorometholone 0.1% (FML) drops and dexamethasone ointment are both used to settle inflammation of the ocular surface and around the eyelid — typically as a short, defined pulse rather than ongoing therapy.

They are used in two situations. The first is the flare: a surface so inflamed that lubricants sting and every other treatment is poorly tolerated. Quieting it makes everything else workable. The second is preparation — settling an angry surface before a device treatment or before cataract surgery, where an unstable, inflamed tear film degrades measurements and outcomes.

Dosing is deliberately time-limited, often a tapering course over days to a few weeks, and the ointment form is frequently reserved for night-time use where lid inflammation is prominent. Steroids are not a long-term dry eye strategy. Prolonged use carries a genuine risk of raised intraocular pressure and, over longer periods, cataract — which is why courses are short, reviewed, and why your optometrist will check your pressures rather than simply repeating the script.

Oral doxycycline: an anti-inflammatory dose, not an antibiotic one

Doxycycline is a tetracycline antibiotic, but in dry eye it is almost never used to kill bacteria. At the low doses used here — commonly 50 mg daily for around three months — the effect that matters is anti-inflammatory: tetracyclines inhibit matrix metalloproteinases, reduce inflammatory mediators at the lid margin, and alter the composition of meibomian secretions so that oil flows more freely.

It is most useful in meibomian gland dysfunction with a strong inflammatory or rosacea component — the same clinical picture that makes IPL a sensible choice, and the two are often used together.

Three months sounds long, and it is: this is a slow-acting treatment and judging it at four weeks will mislead you. Practical points worth knowing before you start — doxycycline causes photosensitivity, which matters in a New Zealand summer; it should not be taken lying down or immediately before bed because of oesophageal irritation; and it is avoided in pregnancy, breastfeeding and in children.

Oral azithromycin: the pulsed alternative

Azithromycin works along similar anti-inflammatory lines but is given in pulses rather than continuously, exploiting its long tissue half-life. Two regimes are in common use: 500 mg daily for three days, repeated in three cycles with a seven-day break between them, or a loading approach of two 250 mg tablets on day one followed by one daily until the course is finished.

The pulsed schedule is its practical advantage — a much shorter total exposure than a three-month doxycycline course, no photosensitivity issue, and an option for patients in whom tetracyclines are unsuitable. Azithromycin does carry a theoretical interaction consideration in patients with cardiac conduction concerns, which is one of the things your optometrist is screening for when they ask about your general health and medications.

Where allergy overlaps dry eye

Allergic eye disease and dry eye travel together often enough that treating one while ignoring the other is a common reason for stalled progress. An itchy, histamine-driven surface is also an inflamed one, and rubbing does further damage.

Olopatadine 0.1% ocular drops are an anti-allergy medication that blocks histamine — a primary inflammatory mediator in allergic reaction. It is typically prescribed twice daily, morning and evening, and is worth knowing that it becomes most effective after around three weeks of continuous use, so a few days' trial proves nothing. Oral antihistamines — fexofenadine, cetirizine or loratadine — are used alongside where the allergic picture is systemic rather than purely ocular, usually for a defined course of around three months.

One caveat patients rarely hear: oral antihistamines are themselves drying. In a patient whose main problem is aqueous deficiency, they can trade an itch for a worse dry eye, which is exactly the judgement call your optometrist is making.

What prescribing does not replace

None of these medicines fixes a blocked gland, clears a colonised lid margin, or replaces a tear film that is not being produced. They lower the inflammatory temperature so that the mechanical work — lid hygiene, heat, expression, device treatment — can actually take hold. A prescription handed over without a diagnosis behind it is a poor substitute for the assessment that should precede it.

Equally, all of these medicines require review. Steroids need pressure checks. Long oral courses need a decision at the end about whether to repeat, and that decision should be based on re-measured signs, not on how you happen to feel that week.

Talk to a specialist practice

Dry Eye Specialist Group member practices are independent, optometrist-owned clinics across New Zealand, and prescribing sits inside a structured plan rather than standing in for one. Find your nearest member practice or see the full range of treatments.

References

• Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: Management and Therapy. American Journal of Ophthalmology. 2025;279:289-386.
• Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. Investigative Ophthalmology & Visual Science. 2011;52(4):1922-1929.
• Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. The Ocular Surface. 2017;15(3):276-283.