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Dry eye experts debate procedural vs. medical therapy for ocular rosacea
One clinician says IPL simplifies treatment; another says the literature does not support its use.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Managing the ocular surface in patients with rosacea can be quite challenging. These patients often have been treated with numerous topical and systemic therapies but continue to struggle. In recent years, intense pulsed light (IPL) treatment has become a more common therapy, but the jury is still out as to whether this can really work.
This month, Laura M. Periman, MD, and Sumitra S. Khandelwal, MD, discuss the use of IPL and medical therapies for the treatment of ocular rosacea. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
IPL a win-win for patients, physicians
Rosacea is an underappreciated contributor to ocular surface disease, which is why it concerns the ophthalmologist. Traditionally, we had topical azithromycin and oral doxycycline or minocycline, but the literature demonstrating their benefit in the group of patients with meibomian gland dysfunction (MGD) secondary to rosacea is not robust. These medications require copayments and often require prior authorizations and staff time, which means the physician is subsidizing the subversive runaround and poor pharmaceutical coverage from insurance companies. Additionally, the prices of the generic versions have recently skyrocketed.
If you take a procedural approach, not only do you eliminate prior authorization, copayment and compliance issues, but now you have an approach that is targeted, specific and effective and greatly improves issues of compliance. The procedural approach provides efficacy and high patient satisfaction as well as an aesthetic benefit. It is easy to integrate, making good medical care a value-added rather than a value-lost proposition.
With the Lumenis Optima IPL therapy system, I have been able to rapidly and effectively control facial rosacea, ocular rosacea and even chalazia while delivering improvement in ocular surface disease signs and symptoms as well as providing an aesthetic benefit to my patients. This approach has lessened the time and staff drains on the practice that are frequently involved when writing a prescription medication.
Decades of IPL research in facial rosacea guides our discoveries in ophthalmology. Our clinical experience mirrors the dozens of peer-reviewed papers describing the use of IPL for MGD — improved signs, symptoms, telangiectasia, osmolarity and inflammation. IPL is a level 2 recommended intervention for MGD and dry eye disease, according to the international Tear Film and Ocular Surface Society Dry Eye Workshop II report.
I have used the IPL system for 2.5 years, with experience with more than 500 treatments. I have been able to get most patients off of their oral doxycycline and minocycline. Maintenance regimens are simpler, and patients report their home lid hygiene and care is faster and more manageable. Patients are maintained on a simple regimen of omega fatty acids and Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Takeda). Cequa (cyclosporine ophthalmic solution 0.09%, Sun) should be available this summer, and I suspect we will see similar benefits as we do with our other immunomodulation medications.
A recent Cochrane review discusses the weak data for using doxycycline and minocycline to manage rosacea compared with other treatments. Oral antibiotics are thought to impact the biodiversity in the gut, and we know that dry eye patients already have decreased gut biodiversity. Adding an antibiotic could be making it worse. Other chronic antibiotic side effects include yeast vaginitis and rarely Clostridium difficile colitis. I have had two cases of chronic rosacea patients treated for years with oral doxycycline or minocycline who required a dacryocystorhinostomy for chronic dacryocystitis. Importantly, the cultures grew out only Candida species. Antibiotics suppress the normal flora in the gastrointestinal, ear, nose and throat, and gynecological mucous membranes.
Source: Laura M. Periman, MD
With the more direct and broad-spectrum approach of IPL, I have moved away from antibiotics in the vast majority of cases. Other prescriptions such as Mirvaso (brimonidine topical gel 0.33%, Galderma), a dermatology-formulated brimonidine, work great for reducing redness. Lumify (brimonidine tartrate ophthalmic solution 0.025%, Bausch + Lomb) improves the redness of the conjunctiva and lid margins, but these medications only temporarily mask the manifestations of rosacea rather than treating it.
The procedural approach allows us to achieve long-lasting correction of the erythema, telangiectasias and lid manifestations of rosacea. Patients love the facial acne rosacea control and skin rejuvenation effects. Additionally, IPL improves MGD by decreasing inflammation and improving meibocyte function through photobiomodulation. IPL also photocoagulates Demodex, which is thought to be a significant factor for many facial and ocular rosacea patients.
Procedural treatment of ocular rosacea is good medicine supported by good science. Improved compliance, high patient satisfaction and reduced practice burdens are added benefits.
- References:
- Craig JP, et al. Ocul Surf. 2017;doi:10.1016/j.jtos.2017.05.008.
- Dell SJ. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S139894.
- van Zuuren EJ, et al. Cochrane Database Syst Rev. 2018;doi:10.1002/14651858.CD003262.pub5.
- For more information:
- Laura M. Periman, MD, can be reached at Evergreen Eye Center, PO Box 25020, Federal Way, WA 98093; email: dryeyemaster@gmail.com.
Disclosure: Periman reports she has financial relationships with Allergan, Eyedetec, Johnson & Johnson, Lumenis, Olympic Ophthalmics, Quidel, ScienceBased Health, Shire/Takeda, Sun, TearLab and Visant.
Medication treatment still first line for ocular rosacea
Ocular rosacea is a chronic, recurrent inflammatory condition involving dermatosis of the face and lid margin. The specific pathogenesis is not known; however, it is theorized that the inflammation is related to natural immunity and abnormal vasomotor function.
Despite the advent of procedural options for ocular rosacea, the literature remains limited to large cohorts of patients rather than randomized controlled trials specific to ocular rosacea. However, there are some excellent reviews in the dermatology literature.
There have been four different councils on rosacea consensus, one of which included three ophthalmologists, and the recommendations include lid hygiene, dietary supplements, topical cyclosporine and doxycycline/minocycline/tetracycline. Topical steroid-sparing anti-inflammatories such as cyclosporine and lifitegrast are available in commercial pharmacies, with higher doses to be available later this year with the FDA approval of cyclosporine 0.09%.
There is no mention of laser-, light- or surgical-based treatment in these panels due to the lack of evidence in rosacea patients specifically. There is just no data to support it at this time. IPL, pulsed dye laser or Nd:YAG laser are recommended in the dermatology literature for telangiectasia specifically. They are recommended as adjunct or synergistic with existing medical management, not as a replacement.
There have been a few studies recently showing improvement with procedural treatment with dry eye and meibomian gland dysfunction.
Craig and colleagues evaluated placebo vs. IPL in dry eye patients, which did not have a true control arm without medications. The lipid layer grade and tear breakup time improved, but not tear evaporation or tear meniscus height.
Toyos and colleagues conducted a 3-year retrospective review of improvement in tear breakup time with the IPL procedure in patients with severe dry eye and saw an improvement in symptoms.
Rong and colleagues showed that meibomian gland yielding secretion and tear breakup time scores improved in eyes with meibomian gland dysfunction receiving IPL treatment and meibomian gland expression, while in control eyes they did not.
However, these studies were wide in their diagnosis of types of dry eye and gland disease. When considering first-line treatment for patients with ocular rosacea, one must specifically consider the costs of treatments not covered by insurance and the risks of a laser or procedural treatment.
Until we have more data comparing procedural treatments to medical management, and considering the fact that the cost of procedural treatment can be an issue for patients, medical management is still the first-line therapy for patients who present with ocular rosacea. However, we look forward to larger prospective studies showcasing enough data to provide better coverage for any procedural treatment for these patients.
- References:
- Craig JP, et al. Invest Ophthalmol Vis Sci. 2015;doi:10.1167/iovs.14-15764.
- Juliandri J, et al. J Cosmet Dermatol. 2019;doi:10.1111/jocd.12903.
- Rong B, et al. Photomed Laser Surg. 2018;doi:10.1089/pho.2017.4402.
- Toyos R, et al. Photomed Laser Surg. 2015;doi:10.1089/pho.2014.3819.
- For more information:
- Sumitra S. Khandelwal, MD, can be reached at Baylor College of Medicine, 1977 Butler Blvd., 2nd Floor, Houston, TX 77030; email: skhandel@bcm.edu.
Disclosure: Khandelwal reports she has a relevant financial interest with Alcon and Zeiss.