OD News Articles

5th July 2017

Ocular Rosacea

by Bruce Flint, OD Kennewick, WA

Rosacea is one of the most overlooked ocular diseases. Left untreated, this condition can have sight-threatening consequences.

The iconic American comedian, W.C. Fields, comes to mind when I mentally picture rosacea. With his bulbous nose and red cheeks, the condition would be hard to miss if we saw his signs in our exam room. But how perceptive are we to earlier and more subtle evidence? It may be surprising that ocular rosacea can sometimes be the first sign of the facial type.

ROSACEA SUBTYPES

Rosacea affects 5% of the adult population and tends to first appear between 30 and 50 years of age. The condition develops more often in those who flush in the face and blush easily. The cause is not fully understood but heredity, environment, and bacteria are all linked.

The disease is divided into 4 subtypes, each with distinct characteristics:

  1. Erythematotelangiectatic rosacea—flushing and persistent facial redness, and may also include visible blood vessels
  2. Papulopustular rosacea—persistent redness with transient bumps and pimples
  3. Phymatous rosacea—skin thickening, often resulting in an enlargement of the nose from excess tissue
  4. Ocular rosacea—ocular manifestations such as dry eye, tearing and burning, swollen eyelids, recurrent styes and potential vision loss from corneal damage

Skin rosacea affects women more often than men, but ocular rosacea impacts men more than women.

SIGNS AND SYMPTOMS

Ocular rosacea has been found to affect up to 60% of rosacea patients. The most common effects of ocular rosacea were documented in a study of 88 rosacea patients at the University of California, Davis1:

  • 85% had meibomian gland dysfunction (MGD)
  • 53% had telangiectatic vessels of the lid rim
  • 44% had blepharitis
  • 41% had bloodshot eyes
  • 16% had corneal scarring
  • 11% had corneal neovascularization

TREATMENT

While we do not understand rosacea’s exact mechanism, we know that it affects blood vessels and meibomian glands and there is an inflammatory response. Although there is no cure for ocular rosacea, it can be effectively treated and controlled. Early ocular rosacea treatment is similar to MGD treatment:
 

  • Lid Hygiene and Massage – Lid hygiene along with gentle massage is the first line of defense. Patients who do not respond to this therapy may receive significant benefit from LipiFlow treatment. LipiFlow (TearScience) is a thermal pulsation device that gained FDA approval in 2011. Its single-use eyepieces apply heat and gentle pressure to the eyelids. The goal is to melt and loosen obstructive oil-clogging material in the meibomian glands. The procedure is done in an office setting and takes about 12 minutes. Other treatment devices are being investigated.
  • Prescription Medication – Cyclosporin (Restasis), azithromycin (AzaSite) and steroid drops have been used with good results. However, steroid drops should only be used short term as they have been associated with corneal melting. Oral antibiotics such as tetracycline (500 mg bid), doxycycline (50 mg bid), minocycline (50 mg bid), and clarithromycin (250 mg bid) can also be very useful. They typically require a longer regimen (6-12 weeks) with slow titration according to clinical response. Another option is Oracea, a 40-mg, controlled-release doxycycline tablet that is taken once a day. While patients may prefer the lowest possible antibiotic dose, there is concern over low doses creating antibiotic resistance.

There is debate as to why oral antibiotics help. Some believe antibiotic action changes the flora of the lids while others think it directly alters fatty acid composition. Either way, we do know there is change in the fatty acid composition of the meibomian glands along with an anti-inflammatory component.

Be mindful that some oral antibiotics (the “cyclines”) can have serious consequences in pregnant females affecting fetal bone and tooth development. It can cause tooth discoloration in developing fetuses and children under ten years old. These drugs can also interfere with oral contraceptives. And patients should also be cautioned to avoid exposure to sunlight as even brief periods of time can cause severe sunburn as well as skin rash, itching, redness or other discoloration. Extended use of antibiotics increases a number of risk factors including infection (especially yeast infections in women), multi drug resistance of bacteria, GI distress, pseudotumor cerebri and allergy.

Oral azithromycin has also been used as an off-label treatment of MGD. The typical prescription is a Z pack of 2 tablets the first day and then QD for 4 days.

  • Supplements – A non-prescription, long-term treatment that has been effective for some individuals is omega 3 fatty acid supplements. These mainly contain fish oil, krill oil or flaxseed oil. Ground flax can also be added to food such as cooked cereal or drinks like orange juice. Amounts may vary by patient, but the label-recommended fish and flaxseed oil dose is 1 to 2 capsules twice a day. This oil can have a laxative effect, so I recommend starting with 1 capsule once a day, increasing after 2 to 4 weeks as needed and tolerated. One study showed eating fish 3 times a week greatly improved lacrimal flow.

The omega supplement is much like using cyclosporine in that we do not expect much change for 4-6 weeks. I caution patients that it may be such a slow change they won’t feel it getting better. But if they stop, it will get worse.

  • Avoid Triggers – Avoid things that aggravate rosacea. Sun exposure and emotional stress are the biggies. Others include hot or spicy foods and drinks, strenuous exercise, alcohol (especially red wine), wind, temperature extremes, hot baths and saunas, some medications and eye cosmetics. Women should use non-oily, fragrance-free eye makeup and avoid using any when their lids are inflamed. There may be other triggers, and what affects one person may not impact another. Although it is impractical and unnecessary for patients to avoid every potential trigger, it is helpful for them to understand and prudently monitor the possibilities.

CONCLUSION

As primary care providers, optometric physicians have a wonderful opportunity to make a difference in the lives of patients suffering from rosacea. Our early diagnosis and treatment can prevent discomfort and irreversible damage. An excellent resource for information and patient education is the National Rosacea Society at www.rosacea.org.

QUESTIONS

If you ever have questions about ocular rosacea, feel free to contact any of our optometric physicians. We are always happy to help.

Source:
  1. Ghanem VC, Mehra N, Wong S, Mannis MJ. The prevalence of ocular signs in acne rosacea: comparing patients from ophthalmology and dermatology clinics. Cornea. 2003;22:230-233.