Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the Meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretions, which may result in alteration of the tear film. Meibomian gland dysfunction (MGD) is classified into two major categories based on Meibomian gland secretion: low-delivery state and high- delivery state. Low-delivery state is further classified into hypo-secretory or obstructive, with cicatricial and non-cicatricial sub-categories. To evaluate the different options in management of meibomian gland dysfunction. This is a prospective, randomized, open-label study. Forty five patients with a diagnosis of posterior blepharitis were enrolled in the study were divided into three groups of patients each have 15 patients received azithromycin. A group received topical, a group received systemic and another group received both topical and systemic azithromycin treatment. All symptoms, signs and special tests improved in all of the three groups with statistically significant difference with P value < 0.05. Both topical and oral azithromycin had beneficial effects in patients with meibomian gland dysfunction (MGD). Topical azithromycin group and combination group were proven to have better effect regarding symptoms and special tests (TBUT and Schirmer). However, systemic group and combination group were found to be more effective in improving Hyperemia and debris. Meibomian gland dysfunction (MGD) could be treated effectively with oral or topical azithromycin by improving symptoms, clinical signs, and stabilization of tear film. However, topical group and combination group seemed to be superior over oral azithromycin in improving the quality of tear film in the short term.