Use multidisciplinary approach with ocular manifestations of dermatologic conditions

Experts in both ophthalmology and dermatology recommend working together to attack minor and major manifestations of dermatologic eye issues.

Patients with manifestations of dermatologic conditions around the eye should be evaluated with both specialties in mind. Physicians in both fields agree that patients with skin diseases around and near the eye can achieve optimal treatments if both specialties are considered.

Mark R. Levine

Mark R. Levine, MD, FACS, called a rapport between the two specialties a mutually beneficial relationship.

“A relationship with the dermatologist and ophthalmologist can be rewarding in both professions because when it comes down to benign and malignant eye lid lesions that are close to the lid margin, the dermatologists are somewhat hesitant if they get closer to the eye, that they’re going to do some harm,” said Dr. Levine, Ocular Surgery News Oculoplastic and Reconstructive Surgery Section Editor. “A dermatologist likes to refer to the ophthalmologist to make the diagnosis or take the biopsy or remove the lesion. So it’s very beneficial to keep a very good relationship with the dermatologist.”

Diagnosis

Dermatologist Lynne Morrison, MD, explained that it is important for surgeons to know their individual comfort levels and to identify any limitations they might have from the standpoint of their field’s training.

“If you see something that involves skin around the eyes, it’s always nice to have dermatology input on that,” Dr. Morrison said. “If they [warts, lesions, etc.] are within the lash margin or closer, I don’t like to do that … That’s ophthalmology territory.”

Dermatologist Stephen Webster, MD, said he refers all lid margins directly to the ophthalmologist.

Jay Justin Older

“I am very sensitive to any lesion on the lid margin, and I’m not comfortable doing any surgery on the lid margin,” he said. “That’s a luxury we have in a medical center. It is harder to do in private practice, but I think most dermatologists will have an ophthalmologist they can work with and talk to.”

Ophthalmologist Jay Justin Older, MD, said he refers patients who might have skin problems to the dermatologist.

“I think each doctor, like with anything else, is going to decide where his limits are,” Dr. Older said.

Dr. Morrison refers to an ophthalmologist on a case-by-case basis.

“I guess it depends on the disease,” Dr. Morrison said. “If someone has rosacea, it’s a fairly chronic disease, and oftentimes, it’ll be more an issue of diagnosis. Based on my concern or suspicion, I’ll call the ophthalmologist and say, ‘Can you work this patient in? They have red eyes in conjunction with a facial rash.’”

To treat such a patient, Dr. Morrison said she consistently communicates with the ophthalmologist.

“We would communicate back and forth, send notes back and forth over the course of the patient’s treatment and let each other know how the treatment is working,” she said.

Basal cell carcinoma on and around the eyelids is a common point of interaction between ophthalmologists and dermatologists. Depending on their skill level, dermatologists might avoid removing basal cell carcinoma when it gets too close to the eye.

This patient has severe blepharitis, which is an ocular manifestation of acne rosacea. If a patient presents with this type of reaction, cooperation with a dermatologist is recommended. Images: Perry JD

Healthy relationships

“I think that we have a healthy collegial relationship,” said ophthalmologist Julian D. Perry, MD. “I think the dermatologists have a very good grasp of more of the lotions and potions that are used around the eyes, and they have a better understanding of the more systemic relationships to some of the skin diseases that we see around the eyes.”

Ophthalmologist John D. Ng, MD, FACS, said there is an overall trend toward a multidisciplinary approach to care, and both specialties can focus on educating each other about the ways diseases can overlap.

“There’s a lot of interchange and cooperation as well as learning from the different practices,” he said. “I think that’s a wonderful atmosphere to work in, and the patients really appreciate that as well.”

Combined treatment

Cicatricial ectropian after derm removal eyelid lesion.

Constant communication with a dermatologist can be necessary, especially when a patient is being treated with medications, Dr. Ng said.

“Many times the dermatologists are involved in treating those [skin conditions] systemically while we as oculoplastic surgeons and ophthalmologists manage the health of the eye,” Dr. Ng said. “There are different medications that we might use in ophthalmology that dermatology may not be aware of and vice versa.”

Dermatologists may use steroid creams for skin disorders surrounding the eye, Dr. Ng said.

“Although not placed on the eyes, if they’re placed around the eyes, there’s always a risk of having secondary complications of cataract formation, ocular irritation and intraocular pressure elevation,” he said.

Dr. Morrison said she relies on the ophthalmologist, particularly in cases of pemphigoid.

“The ophthalmologist needs to tell me, ‘Yep, you’re doing a good job with the medicines. Keep on doing what you’re doing.’ Or they call back. I prefer if they call or communicate if [the medication] urgently needs to be changed,” Dr. Morrison said. “It’s just important to stay in contact. I think sometimes physicians will take good care of their patients, but we may not communicate with each other about what we’re doing.”

Future treatments

In the future, patients may see dermatologists more for quasi-surgical procedures and ophthalmologists more for surgical procedures, according to Dr. Perry.

“I think they [dermatologists] will be offering more less-invasive, quasi-surgical procedures for skin conditions around the eyes, both cosmetic and functional, like rosacea, and ophthalmologists will be offering the same thing, but I think it will largely depend on the scope of the particular ophthalmologist’s practice,” Dr. Perry said.

There is a strong focus right now on minimally invasive procedures across the board, Dr. Ng said.

Some of the recent advances being used by both specialties include Restylane (hyaluronic acid gel, Medicis), Botox (botulinum toxin type A, Allergan) and contour threads, according to Dr. Older.

“I think the cosmetic issue is what’s hot now,” he said. “Less-invasive cosmetic procedures around the face are new, and they certainly include dermatology and ophthalmology.”

For Your Information:

• Mark R. Levine, MD, FACS, can be reached at University Suburban Health Center, 1611 South Green Road, Suite 306A, South Euclid, OH 44121; 216-291-9770; fax: 216-291-0550.
• Lynne Morrison, MD, can be reached at Department of Dermatology, OP06, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239; 503-418-3376; e-mail: morrisol@ohsu.edu.
• John D. Ng, MD, FACS, can be reached at Oregon Health & Science University, Ophthalmic Facial Plastics Division, Casey Eye Institute, 3375 SW Terwilliger Blvd., Portland, OR 97239; 503-494-3010; e-mail: NGJ@ohsu.edu.
• Jay Justin Older, MD, can be reached at Older & Slonim Eyelid Institute, 4444 E. Fletcher Ave, Suite D, Tampa, FL 33613; 813-971-3846; e-mail: jolder1@tampabay.rr.com.
• Julian D. Perry, MD, can be reached at Cole Eye Institute, Department of Ophthalmic and Plastic Orbital Surgery, 9500 Euclid Ave., Dept. I-20, Cleveland, OH 44195; 216-444-3635; e-mail: perryj1@ccf.org.
• Stephen Webster, MD, can be reached at Gundersen Lutheran Medical Center, 1900 South Ave., La Crosse, WI 54601; 608-446-8809; fax: 608-775-6361; e-mail: sbwebste@gundluth.org.

• Katrina Altersitz and Daniele Cruz are OSN Staff Writers who cover all aspects of ophthalmology. OSN Staff Writer Erin L. Boyle contributed to this report.