Treating Ocular Rosacea

A brief but quite well written article about Treating Ocular Rosacea from the American Academy of Ophthamology’s EyeNet Magazine online. This paper gives the high level approach of how to get ocular rosacea under control.

How to Treat Ocular Rosacea, Roger M. Kaldawy, MD, John E. Sutphin, MD, And Michael D. Wagoner, MD. Edited By Sharon Fekrat, MD, And Ingrid U. Scott, MD, MPH

Pathophysiology

Tear film disturbances are responsible for the vast majority of subjective complaints and objective findings in ocular rosacea. The reduced amount and altered character of meibomian gland secretions result in destabilization of the lipid portion of the tear film and increased tear evaporation rates. More than one-third of patients with rosacea also have impaired aqueous tear secretion, further contributing to ocular surface desiccation.

The most serious complications of ocular rosacea probably result from reactions of the sclera, limbus and cornea to staphylococcal endotoxins or cell-mediated hypersensitivity responses to staphylococcal antigens. The variability in response of patients with ocular rosacea to these immune reactions may account for the extreme variability in clinical signs and symptoms associated with this disorder.

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Drug Treatment

Tetracycline derivatives are the mainstay of therapy for ocular rosacea. Our standard regimen is to start with 100 milligrams of doxycycline orally twice a day for one month, after which it is used once daily for at least two more months.

Therapeutic response. Patients are advised that there will be a delayed therapeutic response of several weeks. At three months, the medication is adjusted according to the therapeutic response: For marked improvement, the medication can be tapered to 100 mg every other day for the next three months. For mild to moderate improvement, 100 mg is continued on a daily basis. After six months, patients may go on “doxycycline vacations” for two to three months. Eventually symptoms will recur in most cases, and periodic reinstitution of low maintenance doses is necessary.

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Three-Step Approach

Tetracycline derivatives are most effective when used in conjunction with the following three-step approach:

1. Normalize tear film disturbance.
   • Warm compresses. These help further minimize meibomian gland obstruction and improve lipid flow into the tear film.
   • Punctal occlusion. Temporary or permanent occlusion is useful if aqueous tear production is deficient.
   • Artificial tear substitutes. These are useful until ocular surface wetting, punctate epitheliopathy and variable vision during prolonged visual tasks have improved.
2. Control bacterial overgrowth.
   • Lid hygiene. This is part of a long-term maintenance program to minimize meibomian gland obstruction, improve lipid flow into the tear film and control bacterial overgrowth.
   • Topical antibiotics. These are useful in the first month of treatment to reduce bacterial flora. Generally, they should be used when acute mucopurulent blepharoconjunctivitis, marginal corneal infiltrates or peripheral ulcerative keratitis are present.
3. Control inflammatory and hypersensitivity reactions.
   • Topical corticosteroids. These are useful in the first month of treatment to reduce ocular surface inflammation. Generally, they should be used if marginal corneal infiltrates, peripheral ulcerative keratitis without progressive thinning and/or vascularization are present.
   • Topical progestational steroids. Compounded medroxyprogesterone 1 percent may be used if peripheral ulcerative keratitis with progressive thinning is present.

In addition, topical progestational steroids are useful in conjunction with corticosteroids for treating progressive vascularization.

• AAO EyeNet: Treating Ocular Rosacea

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