Ophthalmologists must be aware of chronic nature of skin disorders

Disease remissions and flare-ups mean varying levels of treatment at different time periods, and more aggressive preoperative prep.

Issue: April 1, 2006

ByJared Schultz

Most dermatologic diseases that affect the ocular surface are chronic, often requiring long-term care.

Diseases such as ocular rosacea that affect the meibomian glands and the lid margins can get worse with age and can have recurrences that may affect future ocular surgery procedures, according to several ophthalmologists.

“Ophthalmologists who follow patients with dermatologic diseases know that most of these diseases are chronic diseases that don’t resolve and that they are going to require long-term care,” said Ocular Surgery News Cornea/Extrenal Disease Section Member Eric Donnenfeld, MD, in a telephone interview.

While melanoma is the most serious dermatologic disease that ophthalmologists have to address, Dr. Donnefeld said the most common problems are those diseases that affect the meibomian glands.

“Rosacea is a chronic problem, and a good systemic history is sometimes very helpful,” he said. “Many times these patients can benefit from oral therapy, and I will occasionally place them on a long-term tetracycline family of antibiotics like doxycycline.”

However, he said that in light of recent studies linking antibiotic use to a risk of breast cancer, he has returned to options like topical ointments and natural supplements.

“I am very reluctant now to use long-term antibiotic therapy in these patients, so I resort back to the basics of the treatment of these systemic diseases that affect the eyelids,” Dr. Donnenfeld said.

Nutritional treatments

Dr. Donnenfeld said that he’s moved heavily to the use of oral flax seed oil and cod liver oil combinations as one of the main stages of therapy, along with recommending hot compresses and simple good lid hygiene to his patients.

“Not only do they help the lid margins, they help the skin in general. They have an anti-collagenalitic effect,” he said. “I think these are very important to be taken systemically.”

He also said that metronidazole gel helps lid margins, as well as topical Restasis (cyclosporine, Allergan), a treatment he called the new star in therapy.

In a study he worked on that was published in the February 2006 issue of Cornea, Dr. Donnenfeld and his colleagues found that topical Restasis opens up meibomian gland orifices, improves tear quality and reduces lid margin inflammation.

“This is a very quiet and unrecognized benefit of Restasis that I think is very significant,” he said.

David R. Hardten, MD, also emphasized the importance of long-term therapies such as cyclosporine in place of steroids.

“In some cases we give them steroids, but we try to stay away from steroid creams, ointments and drops because of their potential for cataract and glaucoma over time,” he told Ocular Surgery News in a phone interview.

Atopic disease and eczema are other dermatologic conditions that can have serious ocular side effects, and Dr. Hardten said he has recommended cyclosporine drops or mast cell stabilizer drops such as Patanol (olopatadine hydrochloride) and Alomast drops for the eye, as well as Protopic (tacrolimus) ointment for the lids.

Dealing with remissions

Ophthalmologists must be aware of the tendency for flares and remissions when thinking long-term. Dr. Hardten explained that it is not possible for ophthalmologists to plan ahead or catch the disease early; they must simply wait for the disease to return.

“Basically there’s nothing you can do until the disease rears its head,” he said.

He said this pertains particularly to eczema, in which flare-ups may require differing degrees of treatment. Some periods of increased disease may require more treatment than others.

“I let the patients self-treat and increase or decrease the treatment once they have learned what works for them,” he said. “If steroids are a part of the treatment, then I will see them every 6 months to a year to monitor their pressure and check for cataract.”

Poor surgical candidates

Future surgical procedures like cataract surgery and refractive surgeries also require a heightened degree of planning when faced with the potential for disease flare-ups, Dr. Donnenfeld said.

He explained that patients with dermatologic diseases affecting the eyes are generally poor candidates for procedures like LASIK and risk surgical complications such as epithelial ingrowths, corneal scarring, neovascularization, irregular astigmatism and flap dislocation.

“These patients for the most part are generally not good candidates, but you have to assess them on an individual basis,” he said.

Dr. Hardten said the only thing to do is to quiet down the disease as much as possible before any type of surgery can even be considered.

“With some patients, you may not be able to quite down the disease process enough to have any of these surgeries, and so we’re oftentimes more aggressive than you would typically be around the time of any ocular surgery,” he said.

For Your Information:

Eric D. Donnenfeld, MD, can be reached at Ryan Medical Arts Bldg., 200 North Village Ave., Rockville Center, NY 11570; 516-766-2519; fax: 516-742-0017. Dr. Donnenfeld is a consultant for Allergan, Alcon, Bausch and Lomb and ISTA.

David R. Hardten, MD, can be reached at Minnesota Eye Consultants, 710 E. 24th St., Suite 106, Minneapolis, MN 55404; 612-813-3632; fax: 612-813-3658.

Reference:

Perry HD, Doshi-Carnevale S, et al. Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction. Cornea. 2006;25:171-175.

Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.