Dr. Mannis in his interview for the RSRP had this to say about IPL and ocular rosacea.

Q: Do you think IPL treatment of the face usually improves ocular rosacea? What about patients who feel that it has made their ocular rosacea worse, eg more veins showing in the white of the eye, lids more sensitive, eyelashes falling out, hot compresses now cause the eyes to swell?

A: Unfortunately, as ophthalmologists, we have very little experience with IPL. That’s something that’s done by and large by dermatologists. I am not aware of any definite ocular side effects from facial treatments with IPL.

Q: Does ocular rosacea increase the likelihood of cataracts or other eye diseases such as macular degeneration, or central serrous corinopathy (retinopathy)?

A: No. But, if IPL is done, there needs to be eye protection. Any kind of laser treatment done on the skin around the eye requires the practitioner to use eye shields to be sure that the globe is not exposed to the intense light in any way. As long as it’s not, then the likelihood of any of those problems occurring is very small.

For more information on Dry Eye see the following articles: Dry Eye: Awareness, Diagnosis, and Management and Dry Eye Syndrome from Sunday Times Sri Lanka

Zapping Dry Eye

Posted: 12:23 pm EDT October 8, 2009

Christopher Coad, M.D., Ophthalmologist at Chelsea Eye & Cosmetic Surgery Associates in New York City, is using a technique for some dry eye patients called intense pulsed light therapy (IPL). IPL is sometimes used to reduce facial skin redness caused by growth of abnormal blood vessels in patients with rosacea. Doctors noticed that some rosacea patients reported easing of dry eye symptoms after getting IPL. That finding led physicians to try it for patients with dry eye.

First, eye shields and a cooling ultrasound gel are placed around the eyes to protect the eyes and surrounding skin. Then, the IPL is aimed under the lower lid, moving across the eyes. Two passes of the light are made. Then the gel and eye shields are removed.

Coad says IPL has three main effects on dry eye. First, the heat acts like a warm compress to liquefy the blocked oil that’s plugging the meibomian gland. Second, the small blood vessels that carry inflammatory cells to the site are sealed. Third, the light treatment improves the health and function of the meibomian gland, reducing the risk of further inflammation.

Related Articles

• claritin, zyrtec and dry eyes
• Dry Eye: Awareness, Diagnosis, and Management
• dry eye and linoleic acid
• Dry Eye Syndrome from Sunday Times Sri Lanka
• cyclosporine (restasis) shows promise for ocular rosacea

Elidel no better than Metrogel for lumps and bumps of rosacea.

A comparison of metronidazole 1% cream and pimecrolimus 1% cream in the treatment of patients with papulopustular rosacea: a randomized open-label clinical trial. Clin Exp Dermatol. 2009 Jul 6

Patients were randomly assigned treatment with either pimecrolimus 1% cream or metronidazole 1% cream for 12 weeks. Pimecrolimus cream is no more efficacious than metronidazole cream in the treatment of PR.

Another bacterial link found ?

Is rosacea another disorder of gut microbes? Curr Gastroenterol Rep. 2009 Aug;11(4):253-4

This paper sounds like it might be heading in the direction to add to some research that looks at small intestinal bacterial overgrowth as a source of rosacea symptoms. Alas all we can see at the moment is the title. Also note that the author has published several other papers that at least in their title link intestinal disorders with diseases such as fibromyalgia as obesity.

Facial blood vessels correlate to Ocular Rosacea Symptoms

This paper, who’s full text is available via the link, suggests that the presence of facial visible blood (telangiectasia) is more of a clue that ocular rosacea may also be present, compared to other facial symptoms like papules and pustules.

Correlation of the severity of cutaneous rosacea with ocular rosacea,  Indian J Dermatol Venereol Leprol 2009;75:405-6.

In our series, ocular involvement did not correlate with the severity of papular, pustular, nodular lesions and flushing but, surprisingly, we found a significant relationship between the severity of telangiectasia and ocular involvement. This finding was not in agreement with the previous studies claiming that the ophthalmologic complications of rosacea are completely independent of the severity of facial rosacea. On the other hand, it seems that the significant relationship between the severity of telangiectasia and eye lesions in our study might be an incidental experience. We agree with the general assumption that skin and eye lesions in rosacea are separate al together.

IAP the link from intestine to Rosacea Skin ?

This paper is proposing that the activity of the enzyme intestinal alkaline phosphatase (IAP) could be the link between an inflammatory response to intestinal bacteria and rosacea skin symptoms.

Intestinal alkaline phosphatase: The molecular link between rosacea and gastrointestinal disease?, Med Hypotheses. 2009 Jun 30 (UMR 168 CNRS/Institut Curie, 11 rue Pierre et Marie Curie, 75005 Paris, France Rosacea Research and Development Institute, Pahala HI 96777, USA)

Rosacea is a common inflammatory condition of the facial skin of unknown etiology, which frequently occurs in combination with gastrointestinal disorders. Many dietary and hormonal factors are known to affect the severity of rosacea symptoms, several of which also modulate the activity of the enzyme intestinal alkaline phosphatase (IAP). The role of IAP in inhibiting an inflammatory response to intestinal bacteria suggests a mechanism by which intestinal pathologies may be linked to the skin inflammation characteristic of rosacea. Analysis of alkaline phosphatase activity is routinely performed on blood samples, and methods to quantify enzyme activity of the intestinal isoform specifically have been described. Correlations between IAP activity and rosacea symptoms in patients and controls can thus be screened by noninvasive and inexpensive means. If IAP activity is found to be low in rosacea patients, acute symptoms could be treated with oral IAP supplementation, and trials of IAP-activating medications currently used in gastrointestinal disease could be initiated in rosacea patients. More importantly, the safe and long-term control of rosacea could be undertaken by patients themselves through dietary modification to naturally increase IAP activity.

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It is good to see more published research backing topical cyclosporine (Restasis, Allergan) as a treatment for ocular rosacea. Restasis (cyclosporine ophthalmic emulsion 0.05%) has been shown to increase tear production and improve the quality of naturally produced tears and is the first approved therapeutic agent for the treatment of chronic dry eye.

Official Use of Restasis

The FDA has approved Restasis as a treatment to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with chronic dry eye. Note that increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs. Restasis is not appropriate for immediate relief for an uncomfortable irritated eye as it may take up to 6 months for maximum improvement. (source The Eye Digest)

Other Evidence

An article from 2006 in Ophthalmology Management Topical cyclosporine proves to be effective in treating rosacea whetted our appetite for this interesting new treatment.

The anti-inflammatory mechanisms of cyclosporine are highly appropriate for the treatment of ocular rosacea, as the condition has been shown to have an inflammatory etiology. Barton and associates conducted a study comparing tear fluid concentrations of interleukin-1alpha (IL-1alpha) and tumor necrosis factor-alpha (TNF-alpha) in ocular rosacea with those in control subjects. Tear turnover was lower in patients with rosacea than in controls, and Schirmer scores were also statistically lower in patients with rosacea than in controls.

After 6 months of use, topical cyclosporine was shown to decrease inflammatory cytokines in the conjunctival epithelium of dry eye patients with increased tear production.

…

Given the excellent side effect profile of topical cyclosporine and its lack of systemic absorption, ophthalmologists should consider utilizing topical cyclosporine in the treatment of patients with ocular rosacea.

Expert Opinion

The Rosacea Support Group asked Dr. Eric Jones, MD, the Medical Director of Devers Eye Institute in Portland, Oregon a related question about Restasis and ocular rosacea.

Q: Do you agree with the view that Restasis won’t help ocular rosacea or dry eye triggered by Accutane?

A: The drug rep was in for Restasis the other day and I asked her about it. We looked it up here and didn’t find any studies that checked on Restasis and ocular rosacea together. It’s a great question because, you know people with ocular rosacea have decreased tear production and, if Restasis can help that, I don’t see why it wouldn’t work.

Recent Abstract

Below is the abstract from the recently published paper, from the same author as the above article, but now appearing in a peer reviewed journal. The above link to Ophthalmology Management leads to a full article, which can be consulted for more details if you don’t have access to the full text of the journal article.

Efficacy of topical cyclosporine for the treatment of ocular rosacea, Adv Ther. 2009 Jun 23, Schechter BA, Katz RS, Friedman LS, Florida Eye Microsurgical Institute.

INTRODUCTION: This study was designed to compare the efficacy of cyclosporine ophthalmic emulsion 0.05% with an artificial tear solution for the treatment of rosacea-associated eyelid and corneal pathology.

METHODS: Double-masked, randomized, 3-month clinical trial of 37 patients with rosacea-associated eyelid and corneal changes (defined as lid margin telangiectasia, meibomian gland inspissation, and/or fullness of the lid margin). All findings were standardized and compared to photographs for grading.

RESULTS: There was a statistically significant increase in Schirmer (with anesthesia) scores of 2.7+/-2.2 mm after 3 months of treatment in the topical cyclosporine group (P<0.001), compared with a mean decrease of -1.4+/-4.6 mm (P=0.271) in the artificial tears group. The mean tear break-up time score significantly improved in the topical cyclosporine group (mean increase of 3.56+/-1.5 seconds, P<0.001), but worsened in the control group, although this change was not significantly significant (mean decrease of -0.04+/-1.6 seconds, P=0.929). The topical cyclosporine group exhibited a significantly greater mean reduction in corneal staining scores (-1.3+/-0.53) compared with the control group (-0.2+/-0.83; between groups P<0.001). The topical cyclosporine group had a greater improvement in Ocular Surface Disease Index scores than those using artificial tears (P=0.022). Limitations of the study included an older, predominantly Caucasian patient population and short trial length.

CONCLUSIONS: Topical cyclosporine 0.05% is more effective than artificial tears for the treatment of rosacea-associated lid and corneal changes.

Related Articles

• Official web site: Restasis
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• Ocular Rosacea: Dr. Eric Jones, MD
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One of inventors of this patent is well known to rosacea sufferers. Dr. Mark Mannis has been friendly and helpful to online rosacea sufferers, see his interview – Ocular Rosacea: Dr. Mark J. Mannis, MD. He has also been mentioned in Rosacea News in the past; wearing contact lenses and ocular rosacea and was a contributor to the standard classification of rosacea.

Rosacea News first highlighted a possible diagnostic test for ocular rosacea in late 2005. The journal article from the Journal of Proteome Research concluded that “The high abundance of oligosaccharides in the tear fluid of patients with rosacea may lead to an objective diagnostic marker for the disease.”

An objective diagnostic test for ocular rosacea would be an excellent achievement for rosacea sufferers. Being able to be definitively diagnosed with ocular rosacea, especially if no other other rosacea symptoms are present, will enable those sufferers to seek immediate treatment. As we all know an accurate diagnosis is almost the most important step in getting better.

United States Patent Application 20090118141, May 7, 2009. METHODS OF OLIGOSACCHARIDE PROFILING FOR THE DETECTION OF OCULAR ROSACEA, Lebrilla; Carlito B.; (Davis, CA) ; An; Hyunjoo; (Davis, CA) ; Alvarenga; Lenio S.; (Sao Paulo, BR) ; Mannis; Mark D.; (Carmichael, CA)

The present invention provides methods for identifying oligosaccharides specific to an inflammatory or infectious disease, methods for diagnosing an inflammatory or infectious disease by detecting the presence or absence of such oligosaccharides, and methods for treating an inflammatory or infectious disease by administering antibodies directed to such oligosaccharides. The present invention also provides methods for diagnosing ocular rosacea by determining the presence or absence of specific oligosaccharide markers. In addition, the present invention provides markers for ocular rosacea comprising 0-linked oligosaccharides as well as kits for diagnosing or treating ocular rosacea.

The patent raises the possibility of an ocular rosacea treatment that uses “a therapeutically effective amount of an antibody that binds specifically to a unique oligosaccharide”. This suggests that a new class of rosacea treatments might arise from this invention.

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The Sunday Times in Colombo has a recent article devoted to Dry Eye Syndrome titled Looking through a dry lens, an interview with Consultant Ophthalmologist Dr. Charith Fonseka from the Eye Hospital in Colombo.

"Dry eye syndrome is usually due to a problem with the quantity and/or quality of the tear film that lubricates the eyes," he says.

…

Bacteria due to an infection, blepharitis, along the eyelids or eyelashes could also breakdown the oil which in turn may result in an inadequate quantity of oil being present.

Aqueous tear deficiency could be caused by either poor production — due to age, hormonal changes or various autoimmune diseases such as primary Sjogren Syndrome, rheumatoid arthritis or lupus — or excessive evaporation – due to an insufficient overlying lipid layer.

…

What of treatment?

Everyone’s needs are a little different, says Dr. Fonseka, with many finding relief simply by using artificial tears regularly. Preservative-free tears are recommended as they are the most soothing and have fewer additives that could be potential irritants.

Artificial tears and lubricating eye-drops and gels, available over-the-counter provide more moisture and lubrication for the surface of the eye. What a person needs to use will depend on what provides the best relief to that person.

Lubricating eye ointments could also be used. As they are thicker than drops and gels, they may provide relief longer but could also blur the vision if used during the day. "That’s why they are recommended for use overnight while you sleep," he says.

…

Urging that it is important to treat dry eyes not only for comfort but also to maintain a healthy cornea, he says, hot compresses and eyelid scrubs/massages with baby shampoo help provide a thicker, more stable lipid layer. Used against meibomian gland dysfunction, rosacea or blepharitis, the heat from the compresses would warm up the oil in the glands, making it flow easily. "Massaging helps get the oil out of the glands and the cleaning process decreases the number of bacteria that breakdown the oil."

Pointing out that simple lifestyle changes can significantly improve dry-eye irritation, Dr. Fonseka says drink eight to 10 glasses of water everyday to keep the body hydrated and flush out the impurities. Blink frequently, especially when reading or watching TV and avoid rubbing the eyes which would worsen the irritation.

If your eyes are dry mainly while watching TV or reading, take frequent breaks, suggests Dr. Fonseka, to allow your eyes to rest and become moist. And his advice: Close your eyes for 10 seconds every 5-10 minutes and also blink to improve eye comfort.

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Here is a good example of why not to believe everything you read on the internet.

Today the internet news stream has a `release’ titled OCuSOFT(R) Lid Scrub(TM) PLUS Proven to Kill Demodex Mites. In it we read ;

“SYNACON/OCuSOFT(R) a broad based supplier of ophthalmic pharmaceuticals and supplies is pleased to announce the latest findings from a recent study(1). OCuSOFT(R) Lid Scrub(TM) PLUS, in its unique “Leave-On” formulation, was shown to effectively eradicate Demodex mites. Significantly, NO other eyelid cleanser used according to manufacturer’s instructions kills Demodex.” (emphasis added)

This is a pretty big claim, and I felt sure that I had never read this before. The brief product description from ocusoft.com says that Lid Scrub Plus is “An Extra Strength eyelid cleanser utilizing a low-level preservative and moisturizer blend offering a wide range of anti bacterial properties.”.

Further reading will reveal that indeed the only claim that is proven is that OCuSOFT Lid Scrub Plus is able to kill “Staphylococcus epidermidis — the most common bacteria associated with blepharitis. This bacteria is often found on the skin and in mucous membranes.” Note that there is no mention of demodex mites.

So the press release is a fabrication, who would have believed it Sadly the internet is full of inaccuracies about demodex mites.

Another page about OCuSOFT based research, Rid the Lid of Disease, reveals more about how their lid scrubs are used in practice.

I use OcuSoft Lid Scrub Plus for all my blepharitis patients. I recommend patients use a hot compress for 10 minutes and follow with the OcuSoft Lid Scrub Plus formulation once a day for two weeks. The hot compress expands the pores and oil glands. This doesn’t necessarily mean the lids absorb the scrub faster, but the product will at least dissolve the hardened meibum.

So eradicating S. epidermis may help your blepharitis symptoms, but what else do we know about demodex mites and ocular symptoms ? We do know that tea tree oil is effective at eradicating ocular demodex and that this might lead to a reduction in ocular rosacea symptoms.

We also know that demodex mites are resistant to a wide range of antiseptic solutions. Some of the products that are known to kill demodex mites include 100% alcohol, tea tree oil, carraway oil, dill weed oil, ether, benzen and xylol. Be careful with carraway oil and dill weed oil as they are toxic to the eye.

So keep an eye out for what you read and believe, especially these sorts of publicity seeking press releases. There may be truths behind press releases, but sometimes you have to dig deeper to see what information is worth taking home.

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My wife believes that our 10-year-old son might have rosacea. She is a sufferer, and he flushes a lot and has a lot of pimple-like bumps. Do children get rosacea?

While rare, cases of rosacea during childhood have been reported in the medical literature. Whether your son has rosacea or not, he may benefit from seeing a dermatologist for a proper examination, diagnosis and treatment as may be appropriate.

…

Also, if your son experiences any eye discomfort, make sure the doctor is informed of this as ocular rosacea may be especially important to identify and treat during childhood.

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`What guidelines should I follow regarding contacts if I have ocular rosacea? Response by Dr. Marian Macsai, vice chairman of ophthalmology at Northwestern University.’

Dr. Macsai’s advice includes comments about soft lenses, using a hydrogen peroxide cleansing fluid, the possible use of artificial tears and having a good eye hygiene routine. The recommendations also include finding a specialist who is familiar with ocular rosacea and ensuring that your corneal surface is closely monitored.

As an aside, I have recently changed to using AO Sept, which is a `hydrogen peroxide + catalyst’ based cleanser. Even though I don’t have ocular rosacea symptoms I do find that the lenses are cleaner than ever and I’m enjoying wearing them more.

Related reading from Dr. Mannis

Also worth reading is background from Dr. Mannis – wearing contact lenses and ocular rosacea. This article is one of the best ocular rosacea and contact lens resources you can find online. Dr. Mannis is well known to rosacea sufferers as a contributor to the Standard Classification of Rosacea as well as contributing to a question and answer session with members of rosacea-support.

More Background

Dr. Mannis and Dr. Macsai have also published research together including the hard-to-find 1996 hardcover, Eye and Skin Disease. Thankfully for rosacea sufferers, we can read the extensive  Chapter 41 Acne Rosacea online.

This book has been described as “The most extensive text/atlas to date on eye and skin diseases, this volume is two books in one–it is both a full and detailed clinical reference and a superb full-color photographic atlas. It provides rapid and reliable access to definitive diagnostic and management guidelines for ophthalmic dysfunction related to dermatologic disease.”

Plenty of background reading there, hope you find these links helpful.

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This phase 2 trial’s purpose is to determine the safety and efficacy of sub-antimicrobial dose doxycycline in the treatment of patients who have both blepharitis and facial rosacea.

The trial is due to complete in July 2008. The conditions treated include Blepharitis, Meibomianitis & Dry Eye. Interestingly the trial participants will take either oracea or a placebo for a period of 84 days. This suggests that 3 months is a reasonable treatment period for Oracea.

We know that Collagenex holds up to 6 patents relating to Oracea. One of these patents, which was highlighted by Rosacea News in May 2006, covers treating ocular and facial rosacea at the same time with one treatment.

A survey from the NRS suggested that eye symptoms are often undiagnosed in rosacea sufferers. Additionally some sufferers of facial rosacea are only diagnosed when their opthamologist finds one of the related conditions such as blepharitis or meibomianitis.

Extending the marketing reach of Oracea to be a FDA approved treatment for ocular rosacea is another sign that Collagenex are serious about growing the market for their products. Even though doxycycline is not new science, it is still a good thing if the revenues generated by Oracea can be re-invested in developing promising new-styled treatments like Sansrosa/COL-118.

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The amniotic membrane transplant was a success, both sealing the perforation, and restoring good vision.

Amniotic membrane transplantation in ocular rosacea.

Ann Ophthalmol (Skokie). 2007;39(1):71-3, Jain AK, Sukhija J

A 40-year-old patient with the diagnosis of acne rosacea presented with perforated peripheral corneal ulcer. Three applications of cyanoacrylate glue along with bandage contact lens failed to seal the perforation. Two months after the presentation, corneal perforation was successfully managed with amniotic membrane transplantation. The final best corrected visual acuity of 6/6 was achieved.

Severe ocular rosacea symptoms like corneal thinning have been seen in around 7% of ocular rosacea sufferers. Research shows that a perforated cornea is very rare. Thankfully there are now a few treatment options available should you develop this condition.

Here is a shot of what the membrane transplant looks like (arrowed). The author kindly supplied a draft copy of the full article (3 pages), email me if you are interested in reading it.

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