Ocular Rosacea Treatment & Management

Rosacea is caused by inherent defects in the body's immune system and vasoregulatory processes. Treatment is directed toward symptomatic control and disease prevention rather than cure.

When treating ocular rosacea, a stepwise approach can be undertaken, using first lid hygiene and artificial tears, followed by topical and oral anti-inflammatory medications, with late surgical intervention as required. Contact lenses should be avoided until the ocular rosacea is controlled.

Lid hygiene

Hot compresses applied to the eyelid margins can help to liquefy the thick meibomian gland secretions and, thus, facilitate their expression. Mild, nonirritating cleaning solutions, such as dilute baby shampoo or commercially prepared eyelid scrubs, can also be applied to the eyelids to remove clogging debris. Additionally, light pressure applied to the eyelids can aid in gland expression. Thermal pulsation to the eyelid (Lipiflow, Intense Pulse Light) is a technique used in the treatment of blepharitis. BlephEx is another emerging technique for the treatment of blepharitis. Some studies have shown improvements in Demodex colony counts and inflammation with the use of 50% tea tree oil scrubs. ^[21]

Artificial tears

Because of the frequency of application, nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.

Immunosuppressive agents

Cyclosporine inhibits various T-cell activities, and topical formulations of cyclosporine have been successfully used for ophthalmic inflammatory conditions. Twice-daily instillations of topical cyclosporine have proven more efficacious than artificial tears in the management of the ocular surface changes and subjective symptoms of ocular rosacea. ^[22]

Antibiotics

Patients with ocular rosacea who are asymptomatic and without worsening eye disease should not be placed on oral antibiotics.

Tetracyclines (eg, tetracycline, doxycycline, minocycline)  ^{[23, 20, 24]}

Tetracyclines represent the most common and most effective treatment regimen for rosacea. These drugs are believed to be effective not primarily as antibiotics but rather through a secondary effect that they exert on the meibomian glands. Tetracyclines decrease bacterial lipase, thereby altering the fatty acid composition of the meibomian gland secretions and improving their solubility. These medications also inhibit collagenase; therefore, they are effective in protecting the cornea from impending perforation secondary to inflammatory responses.

Adverse effects are predominantly GI, including diarrhea and, rarely, pancreatitis and pseudomembranous colitis. In these patients, enteric-coated tetracyclines such as Doryx (a form of enteric-coated doxycycline) are a promising option. The special coating prevents the medication from dissolving in the stomach where it may induce GI upset. Instead, the medication is broken down in the small intestine from where it readily enters the blood stream. More severe but much less common adverse effects include benign intracranial hypertension and renal tubular damage (Fanconi syndrome) from outdated medications. Additionally, tetracyclines cross the placenta and can cause permanent discoloration of teeth as well as fetal bone growth retardation.

Tetracyclines generally are effective for rosacea in doses much lower than those given for antibiotic effect, and, once the disease has come under control, the dose may be tapered to a lower, suppressive dose and maintained indefinitely. Because of the chronic, relapsing nature of rosacea, the medication may be used chronically at suppressive doses or discontinued and restarted if and when symptoms recur.

Among this class of medications, tetracycline and doxycycline are most commonly used. These two medications are quite similar in their mechanism of action, adverse effect profile, and efficacy, but slight differences do exist. Tetracycline has a shorter half-life and, thus, is dosed 4 times per day, as opposed to doxycycline, which is given twice per day or once per day. Frucht-Pery et al reported a more rapid therapeutic response to tetracycline; however, no difference was found at 6 months. ^[15]

In 2006, the first FDA-approved oral treatment for rosacea became available: a controlled-release form of doxycycline called Oracea (Galderma Laboratories L.P). The 40-mg tablet is a combination of 30 mg of immediate-release and 10 mg of delayed-release doxycycline. The low dose enables the medication to have anti-inflammatory properties without exerting significant antibacterial properties, allowing for a more improved side effect profile and decrease rates of bacterial resistance.

Topical azithromycin eye drops have also gained popularity in the treatment of ocular rosacea. Ocular rosacea often results in severe and recalcitrant blepharitis. Azasite (azithromycin 1%, Inspire Pharmaceuticals) currently FDA approved only to treat bacterial conjunctivitis has found an off label use in the treatment of meibomian gland dysfunction.

Erythromycin can be taken orally for patients intolerant to, or too young for, tetracyclines. Erythromycin ointment applied to the lid margins once or twice daily can provide lubrication for the eye and reduce the bacterial overgrowth contributing to lid margin disease.

Clarithromycin has shown efficacy in treating rosacea. This compound exhibits anti-inflammatory effects as well as activity against H pylori. Torresani compared clarithromycin and doxycycline and found equivalent therapeutic responses and a milder adverse effect profile for clarithromycin. ^[25]

Metronidazole

Metronidazole exhibits antimicrobial (antibacterial and antiparasitic), anti-inflammatory, and immunosuppressive properties and has been found to be effective against rosacea. In fact, oral metronidazole has been advocated as first-line therapy. Adverse effects include gastrointestinal irritation and a disulfiramlike action; thus, abstinence from alcohol is required.

Topical metronidazole is quite effective in treating skin lesions in rosacea. While not approved for ophthalmic use, in a pilot study, Barnhorst et al found the topical compound to be safe and effective in treating eyelid involvement in ocular rosacea. ^[26]

Topical steroids

Topical steroids can prove useful for short-term exacerbations of lid disease and management of inflammatory keratitis. However, steroids should be used cautiously and discontinued as soon as possible to prevent corneal melting. Topical steroids may lead to rosacea exacerbations and should be avoided if possible.

Retinoids

Vitamin A derivatives, such as oral isotretinoin and topical tretinoin, have been found effective in reducing the inflammatory lesions in rosacea. This appears to be accomplished via the suppression of sebum production and a subsequent reduction in sebaceous follicle size. Additionally, tretinoin may help restore sun-damaged skin through the increased production of type 1 collagen in damaged regions. Both compounds can actually cause severe erythema and blepharoconjunctivitis, worsen telangiectasias, and lead to severe keratitis. Additionally, retinoids are extremely teratogenic and, thus, must never be used during pregnancy. Therefore, the use of retinoids is commonly reserved for cases in which multiple agents have failed.

Antiulcer therapy

H pylori plays an as yet undetermined role in rosacea, and some have advocated H pylori eradication in the treatment of rosacea. Thus, in some cases of rosacea, antiulcer combination regimens, such as amoxicillin or clarithromycin, metronidazole, bismuth, and an H2 antagonist, have been used with varying efficacy.

Other treatments

Other treatments in the treatment of rosacea include intense pulsed light therapy, ablative lasers, and electrosurgical loop. ^[27]

See the list below:

• Treatment of dry eye - Punctal occlusion can be accomplished via permanent silicone plugs or punctal cauterization.

• Amniotic membrane - Amniotic membrane has anti-inflammatory properties and promotes reepithelization of the cornea. It can be used to reconstruct the corneal surface in severe cases of rosacea when a nonhealing epithelial defect, corneal ulceration, or limbal stem cell deficiency are present.

• Treatment of corneal perforations

  • Cyanoacrylate tissue adhesive

  • Lamellar keratoplasty

  • Penetrating keratoplasty

• Restoration of vision from corneal disease

  • Penetrating keratoplasty

  • The success rate for graft survival is generally much lower than for noninflammatory conditions because of the increased vascularization of the host cornea.

• Treatment of limbal stem cell deficiency - Limbal stem cell transplant

A dermatology consult is recommended for the optimal management of rosacea.

Avoidance of triggers, such as hot, spicy foods, alcohol, and heated beverages, can reduce symptomatic episodes.

Avoidance of sunlight can be beneficial for some patients.

Eyes undergoing penetrating keratoplasty are more likely to experience graft rejection than eyes without rosacea because of the increased inflammatory response and the relatively increased corneal vasculature.

Patients should avoid trigger foods and situations.

For some patients, avoidance of sunlight can minimize flare-ups.

Rosacea is a chronic condition, and long-term management is necessary to control this disease.

Dermatology and ophthalmology visits may be necessary, and they could initially be frequent to gain control over the symptoms or to protect an endangered cornea.

Inpatient care is rarely necessary, except in some cases of corneal perforations or severe secondary corneal infections.