Ocular rosacea treatments

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Ocular rosacea treatments
Nov 1, 2007
Louise Gagnon
Dermatology Times

Key Points
One of the concerns in ocular rosacea is the possibility of secondary infection, since a dry environment is a good breeding ground for bacteria like staphylococci
Protocols to treat the disease from an ophthalmology standpoint do not differ greatly from what dermatologists offer Û systemic tetracyclines are the mainstay of treatment
Collaboration between dermatologist and ophthalmologist is essential in treating ocular rosacea

National report Û There is no gold standard treatment for ocular rosacea, but communication between the dermatologist and ophthalmologist is a healthy step toward ward determining an appropriate course of care for the condition.

Ocular rosacea is characterized by dry, red eyes. It can occur in isolation or as part of generalized rosacea, says Alan Shalita, M.D., distinguished teaching professor and chair in the department of dermatology at SUNY Downstate Medical Center, Brooklyn, New York.

"I have stayed away from treating the condition with steroids because of a rebound phenomenon. The use of steroids can make things worse, particularly if patients have used topical steroids over the long term," Dr. Shalita tells Dermatology Times.

One of the concerns in ocular rosacea is the possibility of secondary infection, since a dry environment is a good breeding ground for bacteria like staphylococci. Treatment for ocular rosacea includes systemic antibiotics such as low-dose doxycycline, he notes.

In the majority of instances, when patients have ocular rosacea, it presents with generalized rosacea, says Mark Mannis, M.D., an ophthalmologist and professor and chairman of the department of ophthalmology and vision science at the University of California, Davis, in Davis, Calif. In about 20 percent of cases, it presents with significant ocular disease and very mild skin disease.

"Even though it's clearly a dermatologic disease, patients will present to the ophthalmologist rather than the dermatologist in those instances," says Dr. Mannis, who describes ocular rosacea as chronic more than recurrent.

"If the patient presents with only ocular findings, then the rosacea is difficult to diagnose," Dr. Mannis says. "It's a skin disease, but can have serious ocular side effects, from chronic irritation to potentially being a blinding disease."

Protocols to treat the disease from an ophthalmology standpoint do not differ greatly from what dermatologists offer. Systemic tetracyclines are the mainstay. These drugs act multifactorially by decreasing bacterial flora and the expression of matrix metalloproteinases, altering meibum secretion, inhibiting the production of bacterial lipases and providing an immunomodulatory effect, Dr. Mannis explains.

Ocular rosacea therapy is aimed at preventing irritation of the ocular surface and controlling inflammation with topical and systemic anti-inflammatory drugs, Dr. Mannis adds. However, ophthalmologists may use short courses of topical steroids for an acute situation of ocular rosacea.

"When patients present with severe ocular rosacea, it usually takes about four to six weeks for the systemic therapy to work adequately," Dr. Mannis says. "One can at least relieve the ocular symptoms in the short term using topical steroids."

For prolonged treatment, Dr. Mannis says ophthalmologists offer topical nonsteroidal anti-inflammatory agents as an adjunct to systemic therapy.

If a delayed diagnosis occurs, permanent changes develop in the architecture of the eyelid, Dr. Mannis explains. In addition, significant corneal damage can occur if a diagnosis is delayed. In the most severe cases, corneal scarring, corneal vascularization, corneal perforation and even blindness can occur with severe chronic inflammation.

"A timely diagnosis is very important for long-term ocular health," he says. "It's a disease that you want to get under control, because a person could potentially lose vision from it in the more severe cases. Any patient with rosacea who has ocular irritation, light sensitivity and a decrease in visual acuity or obvious inflammation of the lids or conjunctiva should be referred to an ophthalmologist."

Significant tear dysfunction or blepharitis can also occur with ocular rosacea, Dr. Mannis notes. If a symptom like blepharitis does occur with ocular rosacea, ophthalmological surgeries such as photorefractive keratectomy or LASIK, both designed to correct vision, would be contraindicated in those patients. More invasive surgery like cataract surgery would also be potentially complicated.

More cross-referral of patients would optimize treatment.

"We feel that these patients would benefit from early intervention of their eye disease," Dr. Mannis says.

Dr. Mannis is performing laboratory research to identify markers to diagnose ocular rosacea, particularly in instances when the skin symptoms are minimal and a diagnosis is challenging.

"We are looking for a diagnostic test, because it's difficult to make the diagnosis when the skin signs are minimal," he says. "We are looking for a marker in the tear film to identify patients with rosacea."

Dr. Mannis and colleagues published a study in 2005 in the Journal of Proteome Research in which they concluded, in a sample of 37 patients, that there was an abundance of specific oligosaccharides in the tear fluid of patients with rosacea, suggesting the potential for an objective diagnostic marker for the disease.

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