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Facial and Ocular Rosacea

What is Rosacea?

Rosacea is a common chronic skin disease in the centrofacial and periocular regions that frequently involves the eye. Classically, rosacea affects patients between the ages of 40 and 59 years and is 3 times more common in women. 


Pathogenesis and Epidemiology

Although the pathogenesis of the disease remains undefined, recent findings suggest that an altered inflammatory response plays an important role in both cutaneous (skin) and ocular rosacea. Ocular manifestations include changes in the lid and surface of the eye.


Ocular Rosacea is incurable. Treatment of ocular rosacea is aimed at preventing irritation of the ocular surface (e.g., lubricants, lid hygiene) and controlling inflammation with topical (drops) and systemic (oral) anti-inflammatory drugs. According to National Rosacea Society estimates, 16 million Americans suffer from acne rosacea, and ophthalmic findings ultimately develop in 58%–72% of rosacea patients.

Diagnostic Features

Persistent facial erythema (redness) associated with periodic intensification by potential trigger factors. Major features include flushing/transient facial erythema (redness), inflammatory pustules, telangiectasia (small abnormal blood vessels on the skin), and ocular manifestations (lid margin telangiectasia, blepharitis, multiple chalazia, and inflammation of the cornea, conjunctiva, and sclera keratitis/conjunctivitis/sclerokeratitis). Minor features include burning sensation of the skin, stinging sensation of the skin, edema, and dry sensation of the skin.


The skin reaction ultimately results in meibomian gland (oil glands of the lid) dysfunction, chronic scarring of the meibomian gland orifices, and eyelid margin telangiectasias, with subsequent tear film instability and debris, tearing, discomfort, photophobia, keratitis, and blurred vision. In its most extreme state the ocular surface disease may even lead to recurrent corneal erosions, corneal ulceration, and corneal perforation.


Triggers

Multiple offending agents may exacerbate the changes inherent to ocular rosacea, commonly known as “triggers.” Specifically, cutaneous (skin) inflammation may worsen after consumption of alcohol, caffeine, chocolate, spicy foods, hot beverages, or dairy products. Prolonged sunlight exposure, hot showers, extreme weather conditions, and physical and emotional stress may aggravate this disease. Astringent agents, topical irritants, and a host of medications (including Amiodarone, topical and nasal steroids, and vitamins B6 and B12) may lead to heightened symptoms.


Avoidance of these agents has emerged as a standard of care to suppress rosacea. Some physicians have advocated the use of mild cleansers and lipid-free soaps.  Sunscreens are used to decrease the impact of sun exposure

Conservative Treatments

Conservative treatments are utilized to address the meibomian (oil) gland dysfunction of ocular rosacea to maintain the patency of the glands, improve their outflow.  Patients are often instructed rub antiseptic sprays into the lids and lashes which helps the condition. (Hypochlorous Acid - Hypochlor - available for purchase at Palm Beach Eye Center) 


Medical Management

A major focus of treatment for ocular rosacea is the management of dry eye disease caused by meibomian gland dysfunction. Artificial tears are used to counteract the ocular surface dryness that results from the cutaneous (skin) inflammation. Similarly, nutritional supplementation with fish oil or flax seed may improve symptoms related to blepharitis. Studies have demonstrated improvements in the subjective symptoms and objective signs of meibomian gland dysfunction with the use of oral omega-3 fatty acids found in fish oil and flax seed.

 

Macsai, M.S. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008; 106: 336–356

Olenik, A., Jimenez-Alfaro, I., Alejandre-Alba, N., and Mahillo-Fernandez, I. A randomized, double-masked study to evaluate the effect of omega-3 fatty acids supplementation in meibomian gland dysfunction. Clin Interv Aging. 2013; 8: 1133–1138


Cyclosporine


Twice-daily instillation of topical cyclosporine, a potent immunosuppressive agent (Restasis) has proven to be effective in the management of the ocular surface changes and subjective symptoms of ocular rosacea. 



Oral Doxycycline


Systemic tetracyclines (doxycycline) are the mainstay of treatment. In studies, 3 months of oral minocycline resulted in clinical improvements in all meibomianitis signs and persisted up to 3 months after discontinuing the drug. In another study low dose doxycycline (20 mg twice a day) therapy was effective in patients with chronic meibomian gland dysfunction that did not respond to conventional therapy.

Pfeffer, I., Borelli, C., Zierhut, M., and Schaller, M. Treatment of ocular rosacea with 40 mg doxycycline in a slow release form. J Dtsch Dermatol Ges. 2011; 9: 904–907

Sanchez J, Somolinos AL, Almodovar PI, Webster G, Bradshaw M, Powala C. A randomized, double-blind, placebo-controlled trial of the combined effect of doxycycline hyclate 20-mg tablets and metronidazole 0.75% topical lotion in the treatment of rosacea. J Am Acad Dermatol. 2005;53:791–797

Del Rosso JQ, Webster GF, Jackson M, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56:791– 802.


Intense pulsed light therapy involves the direct application of light to the skin with a broad array of wavelengths. In the setting of ocular rosacea, the light is absorbed by the abnormal blood vessels on the skin, causing subsequent closure of the vessels, and healing of the skin. Although the benefits of this intervention have not been specifically assessed in ocular rosacea, the results of this modality in meibomian gland dysfunction are promising. 


Toyos, R., McGill, W., and Briscoe, D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015; 33: 41–46

Craig, J.P., Chen, Y.H., and Turnbull, P.R. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015; 56: 1965–1970

Punctal occlusion (plugs) should be employed in the setting of severe dry eye disease. Recurrent chalazia often develop in patients, and they may require steroid injections or drainage. Given the risks of recurrent corneal ulceration, patients may require tissue adhesives, amniotic membrane placement, or conjunctival flaps. Corneal perforations may necessitate penetrating keratoplasties (corneal transplants).

Oltz, M. and Check, J. Rosacea and its ocular manifestations. Optometry. 2011; 82: 92–103

Vieira, A.C., Hofling-Lima, A.L., and Mannis, M.J. Ocular rosacea–a review. Arq Bras Oftalmol. 2012;75: 363–369



LipiFlow is a promising technique which utilizes a combination of heat application and mechanical stimulation to the eyelid, with the intent of “milking” the meibomian glands (oil glands in the eyelids) to facilitate the extrusion of the meibomian gland oils. Although it has not been directly studied in the setting of rosacea, LipiFlow has proven effective in the setting of dry eye disease and thus presumably offers therapeutic relief for rosacea patients. Future investigations will be needed to focus on the impact of this intervention in rosacea-related meibomian gland disease.

Lane, S.S., DuBiner, H.B., Epstein, R.J. et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012; 31: 396–404

LipiFlow is offered at Palm Beach Eye Center (PBEC) for the treatment of Meibomian Gland Dysfunction and Dry Eye Disease.

Ask your PBEC ophthalmologist about LipiFlow. 


Laser therapy has not been extensively studied in the management of ocular rosacea

As our understanding of the biology of rosacea expands, the therapeutic options to treat this disorder will likely expand and become increasingly specific and efficacious.