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Nonspecific ocular symptoms can indicate ocular rosacea
Acne rosacea is a chronic condition characterized by acute exacerbations of the skin. Manifestations include persistent erythema, telangiectasias, papules, pustules and sebaceous gland hypertrophy in the flush areas of the face and neck. Rhinophyma and hypertrophy of the sebaceous glands of the nose are considered hallmark signs of what is known as facial rosacea. The common age range of those affected with rosacea is 40 to 50 years. Rosacea without ocular involvement involves women twice as often as men. However, no gender difference is found among those who manifest ocular findings.
Signs and symptoms
Ocular involvement (ocular rosacea) is reported in up to 58% of cases of acne rosacea and may range from mild to severe, despite only minimal facial findings. For the eye care specialist to diagnose rosacea with certainty, it is necessary to recognize its variable features. In patients who have both dermatologic and ocular manifestations of rosacea, 20% develop their ocular manifestations first, 53% develop their dermatologic lesions first and 27% develop both dermatologic and ocular signs simultaneously.
Patients will commonly complain of nonspecific ocular symptoms, including foreign body sensation, dryness, burning, epiphora or redness. Patients’ symptoms are frequently out of proportion to the clinical findings. Blepharitis, conjunctival injection, tearing, burning, recurrent chalazion, corneal and scleral perforation, episcleritis and iritis are all documented signs and symptoms. Lid margin telangiectasis is among the most commonly reported clinical findings, seen in 81% of patients. Meibomian gland dysfunction has been reported in 78% and blepharitis in 65%.
Conjunctival injection with mild hyperemia involving the bulbar conjunctiva is frequent. The corneal manifestations of rosacea include a superficial punctate keratitis involving the lower third of the cornea. The keratitis can progress, leading to peripheral corneal vascularization, pannus as well as subepithelial infiltration. These infrequent but plausible corneal manifestations can allow untreated rosacea to become sight threatening.
Unclear pathophysiology
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Multiple mechanisms have been postulated regarding the pathophysiology; however, the definitive cause is yet unclear. Commonly, the initial presentation of rosacea involves flushing reactions and erythema. This has prompted many studies on possible vasomotor etiologies. Although the blood vessels in the upper dermis of rosacea patients have been found to be markedly dilated, no primary vascular damage has been found.
Multiple infectious etiologies have been postulated in the literature. Staphylococcus aureus has been linked to 60% of patients with rosacea. It has frequently been isolated from the lid margins. Such bacteria have been shown to produce biochemical abnormalities in the meibomian glands leading to an unstable tear film and local ocular irritation. However, recent studies demonstrate that cultures of rosacea patients return sterile.
The organism Helicobacter pylori, found in the intestinal tract, has recently been implicated with rosacea and, interestingly, glaucoma. This may, in part, help explain the disease’s chronic nature along with its failure to respond to topical medications alone.
The mite Demodex folliculorum has also been investigated as a possible etiology, as it has been isolated in the skin of patients with rosacea. The etiology is controversial as other researchers have published information indicating that its incidence in infected patients is no higher than that of the general population.
Overall, no infectious or vasoregulatory disturbance has been conclusively proven to account for the inflammation found in rosacea patients. Multiple studies continue to search for a significant underlying etiology.
Hygiene, orals, steroids
The mainstay of rosacea therapy involves educating patients to improve hygiene. The majority of patients with ocular rosacea have meibomian gland dysfunction and blepharitis. This increases their incidence of hordeolum and chalazion. A chronic regimen of lid hygiene and warm compresses can reduce outbreaks and recurrences and should not be discounted. Oral medications are suggested for the symptomatic patients in whom lid hygiene fails to resolve all of their signs and symptoms.
Many patients fall into what is referred to by dermatologists as steroid addiction. Because mild steroids and medications containing steroids can temporarily eliminate the dermatological sequelae, patients, once they observe that benefit, gravitate toward chronic use without eradicating the underlying cause. The steroids can thin the dermis by reducing the cellular turnover. This actually creates additional long-term difficulties. If a topical steroid must be prescribed, it should be in the form of an over-the-counter, low-dose hydrocortisone, applied in a thin film to affected areas.
An oral regimen will also help. The appropriate oral medication is 250 mg four times a day or 500 mg twice a day of tetracycline or 100 mg twice a day of doxycycline. Tetracycline has been anecdotally and scientifically proven to alleviate patients’ symptoms the fastest; however, doxycycline causes fewer gastrointestinal side effects and is easier comply with.
Erythromycin, in the same dosages, can be substituted in children younger than 10, in nursing mothers and in women in the childbearing years. Low-dose maintenance therapy may be necessary in recalcitrant cases.
Topical medicines include metronidazole ointment, metronidazole cream 1%, medicated shampoos, such as ketoconazole and ketoconazole 2% cream, and topical antibiotic.
Omega-3 supplementation with EPA-enriched flaxseed oil may address the ocular dryness, according to Jeffrey P. Gilbard, MD. Once eaten, omega-3s – essential fatty acids — are acted upon by enzymes in the body to produce prostaglandin E3 and leukotriene B5, two eicosanoids that decrease inflammation. Meibomianitis patients taking omega-3 supplements have experienced relief from eye irritation upon waking. Essential fatty acids are also used by the meibomian glands to manufacture the oil layer of the tear film. Studies have shown that the polar lipid profiles of meibomian gland secretions in female Sjogren’s patients are controlled by the dietary intake of omega-3 essential fatty acids.
For Your Information:
- Mira Silbert Aumiller, OD, is completing her primary care residency at the Eye Institute and The Pennsylvania College of Optometry. She can be reached at the Pennsylvania College of Optometry, 1200 West Godfrey Ave., Philadelphia, PA 19141; e-mail: MAumiller@pco.edu.