Ocular Rosacea

Rosacea is a commonly encountered disorder characterized by recurrent inflammation of the skin and defined by axial facial erythema, vascular di­lation, seborrheic hypertrophy and the formation of facial telangiectases, papules and pustules.^2-5 The National Rosacea Society has re­cently published a classification and nosology of rosacea, based on signs and symptoms.⁶ Ocular rosacea is defined as a distinct sub-type of the disease.

Figure 1. Two patients with the typical distribution of roseatic inflammation of the “flush” or axial areas of the face.

The classification defines ocular rosacea as characterized by one or more of the following signs and symptoms: interpalpebral conjunctival hyperemia; foreign body sensation; burning or stinging; dryness; itching, light sensitivity; blurred vision; telangiectases of the conjunctiva and lid mar­gin; and lid and periocular erythema. Bleph­a­ritis and meibomian gland dysfunction with chalazion, chronic staphy­­lococcal infection and recurrent hordeolum are common signs of ocular rosacea. Corneal complications include punctate keratitis, corneal in­fil­trates/­ulcers or marginal keratitis. Ocular rosacea is most frequently diagnosed when cutaneous signs and symptoms of rosacea are also present, al­though the diagnosis can be made in the ab­sence of the classic skin manifestations. Ocular signs and symptoms may appear before cutaneous manifestations in up to 20 percent of pa­tients with ocular rosacea. Approximately half of patients experience skin lesions first, and a minority have both manifestations simultaneously.⁴

Ocular rosacea, therefore, is a distinct clinical sub-classification of the systemic disease that most com­mon­ly presents in the context of typical facial findings. It is, nonetheless, important for the eye-care provider to recognize both the typical fa­cial features of the disease as well as the specific lid margin signs that signal ocular rosacea even in the absence of characteristic dermatologic findings.

Table 1 summarizes the dermatologic and ocular features.³ All too often, the eye-care provider does not carefully observe the quality of the patient’s skin, nor, conversely, does the dermatologist look critically at eye findings.⁷ None­the­less, the literature suggests that as much as 6 percent of cornea/external disease sub­specialty practice may consist of ro­sa­cea-related problems.⁸ Now that ro­sa­cea is a far more commonly recognized entity, this percentage is likely higher.

If rosacea is suspected, as it should be in any case of chronic or recurrent ocular surface inflammation, the practitioner should assess the patient for axial erythema, telangiectases of the facial skin (particularly the forehead, nose, axial cheeks and chin), and generalized seborrheic hypertrophy (See Figure 1). At the slit lamp, the lid margins should be carefully inspected for significant meibomian gland dysfunction and the characteristic filigree telangiectasia of the lid margin (See Figure 3). Moreover, the pa­tient with ocular rosacea will characteristically exhibit interpalpebral conjunctival hyperemia (See Figure 4). Tear dys­function is most commonly evaporative in nature in the rosacea patient due to meibomian gland dysfunction. Aque­ous-deficiency dry eye may, however, also may be present, complicating the man­agement in older patients with rosacea.

General Management Principles

Once the diagnosis of rosacea or ocular rosacea is established clinically, the general management protocol includes:

Figure 4. A. Active corneal spade-shaped peripheral infiltrates in the rosacea patient. B. Moderate scarring and vascularization due to previous inflammation. C. Dense scarring of the central cornea.

1) Lid hygiene to minimize the in­flam­mation and evaporative effects in­duced by meibomian gland dysfunction;

2) Systemic treatment of the rosacea with doxycycline, tetracycline or related medications;

3) Standard treatment of dry-eye signs and symp­toms with supplemental artificial tears (See Table 2). In our own practice, the use of topical cyclosporine has been helpful in this subset of pa­tients not only because of its effects on aqueous tear production but, in ad­dition, due to its anti-inflammatory effect.

4) In severely inflamed patients, we use a topical corticosteroid on a short-term basis to control inflammation while long­er-term anti-inflammatory therapies may be of value if the patient is care­fully monitored. There may also be some evidence that dietary alterations to include a shift from omega-6 fatty acids to an omega-3-predominant diet may both mod­ulate tear production and ocular sur­face inflammation.⁹ Finally, we recommend that pa­tients drink plenty of water and reduce their in­take of caffeinated beverages.

Contact Lens Fitting

A successful contact lens fit in a pa­tient with ocular rosacea re­quires: 1) control of the generalized inflammatory symptoms of rosacea; 2) stabilization of the tear film to ensure both the amount and the adherence of the tears; and 3) re­latively normal lid margins and function. As­suming that this has been achieved with the general and local ocular treatments, the fitter can proceed to choosing a contact lens that is optimal for the patient.

Both gas permeable and soft contact lenses are options for patients with rosacea. GP lenses have the advantage of producing less stress to the surface tear supply. The smaller size of these lenses allows tear ex­change and debris removal. Also, the cornea receives two to three times the amount of oxygen compared to most soft contact lenses. On the other hand, there is greater mechanical trauma with a GP lens. Newer, high-Dk GP lens­es also allow im­proved comfort compared to older-generation GP lenses.

Soft lenses also have both advantages and disadvantages in this setting. Hydrophilic lenses tend to “steal” fluid from the ocular surface rendering them more inflammogenic even if less mechanically traumatic. For this reason, if a hy­dro­philic material is the choice, patients with controlled rosacea are best fitted with loosely fitting, low water content lenses, which maximize spreading of the tear film on the ocular surface and minimize imbibition of the surface tear film. Several low water content lenses are now available for the dry-eye patient. With the advancement in silicone-hy­dro­gel technology, many different choices of low water content lenses are now available. Frequent re­place­ment of soft contact lenses is ad­van­ta­geous to reduce protein and lipid build­­up on the surface of the contact lens. Daily wear, two-week replacement lenses work well for most patients, al­though some patients benefit from one- day replacement of contact lenses.

For both GP and soft contact lens wear­­ers, the use of artificial tears with contact lenses benefits the patient by increasing contact lens wearing time. However, even with the use of artificial tears, some patients may only be able to wear their contact lenses for a limited amount of time.

The selection of a contact lens solution is important for both GP and soft contact lenses. It is particularly important to keep the surface of the contact lens as clean as possible. There have been advances in both types of lens solutions to do so. For soft contact lenses, we particularly like hydrogen peroxide-based systems to eliminate contact lens surface debris.

Special care must also be taken to assess and monitor the corneal surface both before and after the lens fitting. Early corneal manifestations of rosacea may include a mild punctate epithelial keratopathy. In more severe cases, the patient may develop peripheral vascular incursion with characteristic “spade-shaped” infiltrates. In the severest of cases, the cornea may develop localized melting, vascularization and scarring, or even perforation (See Figure 2). Prior to lens fitting, the health of the corneal epithelium should be optimized ensuring that the corneal surface is lustrous and without staining. Any suggestion of limbal vascularization should be noted and monitored closely after lens fitting, especially if a hydrophilic material is chosen. Progression of vascularization should signal discontinuation of lens wear and a reassessment of the suitability of the patient for contact lenses.

The fitting of a contact lens in the rosacea patient adds stress to an already inflamed ocular surface. The successful fitting of a contact lens in the patient with ocular or generalized rosacea requires: 1) Careful assessment of the inflammatory status of the ocular surface and adnexa; 2) “Nor­mal­i­za­tion” or, at least, “optimization” of the ocular surface with lid hygiene, systemic therapy of the rosacea, and tear-film supplementation; 3) The choice of an appropriate lens material and design for the roseatic surface; and 4) Close monitoring of the lens and its effect on the conjunctival and corneal surfaces in the con­text of the disease. If the fitter adheres to these principles, most patients with systemic or ocular rosacea can be fitted with good functional results and a minimum of contact lens-related adverse reactions.

Drs. Mannis and Barnett are in the Department of Oph­thalmology & Vision Science, University of California, Davis. Contact Dr. Mannis at De­partment of Ophthalmology & Vi­sion Science, 4860 Y St., Suite 2400, Sac­ramento, CA 95817.

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