STEP 1: FIND A QUALIFIED PHYSICIAN



1. Search for an Ophthalmologist:

Rosacea sufferers should be examined by medical eye specialists
because ocular rosacea usually presents with multiple symptoms that
may confuse general physicians. Most medical eye specialists
(ophthalmologists) are qualified to treat ocular rosacea.




2. Help the Ophthalmologist:

Rosacea sufferers can help their physicians by answering a few key
questions such as:

• Do your ocular symptoms get worse during bouts of facial flushing?

• Are your ocular symptoms the most troublesome in the morning, or
do they get worse as the day progresses?

• Do you experience blurred vision, eye pain, or vision loss?

• What are your most bothersome symptoms?

• Do you wear contact lenses and if so, what type?

• What medications are you currently taking (include a complete
list)?




STEP 2: BASIC OCULAR THERAPY


The major goals of ocular therapy are to decrease eye surface
inflammation, reduce eyelid inflammation, and normalize the tear
film (oil, water, and mucous layers). As with any disorder, it is
wise to start with the simplest and safest therapies. Most ocular
rosacea sufferers will get significant relief with eyelid scrubs,
artificial tears, oral antibiotics, nutritional therapy, and
elimination of eye irritants. So this is a good place to start.



1. Eyelid Scrubs:

Daily eyelid scrubs are one of the most important parts of the
ocular rosacea treatment regimen. Ophthalmologists who specialize in
ocular rosacea stress that meticulous eyelid hygiene must be
performed daily (and sometimes twice daily) in order to keep this
chronic disorder under control. Proper eyelid hygiene can relieve
most eyelid and eye surface symptoms:

• It removes eyelid crusting, scaling, and microorganisms (yeast &
bacteria).

• It decreases eyelid inflammation, itching, and burning
sensations.

•It increases tear film stability by unblocking meibomian glands and
increasing flow of protective oil.


General physicians routinely recommend that patients use "home-made"
cleansing solutions with dilute baby shampoo to cleanse their
eyelids. These "home-made" cleansing solutions work fairly well on
simple cases like dry eye and eyelid crusting, but these solutions
are not advisable for ocular rosacea sufferers. First of all, dilute
baby shampoo causes eye irritation and stinging in many ocular
rosacea sufferers. Second, dilute baby shampoo is not as effective
as ophthalmologist-designed eyelid scrubs. For these reasons,
medical experts strongly recommend that ocular rosacea sufferers use
commercially available eyelid scrubs.



Recommended Eyelid Scrubs for Ocular Rosacea

a. Ocusoft Eyelid Scrub for Sensitive Eyes (Ocusoft Inc.)

b. Eye Scrub Sterile Eyelid Cleanser
(Ciba Vision Ophthalmics)



Methods for Thorough, Gentle Eyelid Cleansing

• Eyelid Scrubs with Q-tips (cotton swabs). It is highly
recommended that ocular rosacea sufferers apply eyelid scrub
solution onto a Q-tip and gently cleanse their upper and lower
eyelids. Q-tips are recommended because they aid in removing crust
and debris from the eyelid. The eyelid skin is very delicate, so
close the eyes and use gentle side-to-side strokes across the eyelid
margins and lashes, being careful not to rub harshly or irritate the
skin. Patients should cleanse each eye for 30 to 60 seconds.
Lather from the eyelid scrub should then be rinsed off or removed
gently with a tissue. This method is also effective for removing
eye make-up and mascara.

• Eyelid Scrubs with Pre-Moistened Pads. Most commercial eyelid
scrubs are also available in convenient pre-moistened cotton pads
that are easy to use and lather up very quickly. For those
sufferers who cannot safely use Q-tips around the eye, pre-moistened
pads are an excellent choice for eyelid cleansing.

• Note: Medical experts stress that eyelid scrubs should become a
permanent part of the patient's routine. Patients should consider
daily eyelid scrubs as important as washing their faces and brushing
their teeth. Disciplined eyelid cleansing will make a difference in
ocular rosacea symptoms.




2. Artificial Tears:

Artificial tears are similar to the eye's own tear layer. They
lubricate the eyes and help maintain normal levels of moisture.
Artificial tears do much more than just add water to the eyes; they
also speed up healing of the eye surface, normalize goblet cell
activity, and decrease ocular inflammation. Artificial tears are
available in many types and brands. When choosing an artificial
tear, ocular rosacea sufferers should only use non-preserved
products, because preservatives can worsen ocular symptoms.



Artificial Tears Recommended for Rosacea

a. Thera Tears (Advanced Vision Research). This is a superb eye
drop for mild, moderate, or severe dry eye. I highly recommend this
eye drop because it is formulated with an electrolyte solution
specially designed to protect and nourish the eye surface (Thera
Tears replicated the electrolyte balance of the human tear film).
Recently, Thera Tears has developed a new preservative-free eye drop
that is available in a multi-dose bottle. Thera Tears in a bottle
contains a patented preserving ingredient that turns into pure
oxygen and water upon contact with the eye. Oxygen and water work
with the Thera Tears formula to provide excellent soothing dry eye
relief.

b. Refresh Plus (Allergan). Refresh Plus is a popular moisturizing
eye drop that is available in single use, preservative-free
containers. This eye drop is a good choice for mild to moderate dry
eyes.

c. Hypo Tears Select (Ciba Vision). Hypo Tears Select is a new
moisturizing eye drop that is available in a multi-dose bottle.
Hypo Tears Select contains a patented preserving ingredient that
turns into oxygen and water upon eye contact. This eye drop is good
for mild to moderate cases of dry eye.

d. Similasan #1 (Similasan Inc). This is a homeopathic eye drop
that is used to soothe mild to moderate dry eyes. Similasan also
relieves redness of the eyes and eyelids. Similasan is a
preservative-free solution that contains extracts of eyebright,
honey bee, and cevadillas.

e. Celluvisc (Allergan). This is a thick eye drop that was
developed for the treatment of severe dry eyes. In general, thicker
eye drops are more effective because they are retained on the eye
surface for longer periods of time. For severe dry eyes,
carboxymethylcellulose sodium (the active ingredient in celluvisc)
is a good choice for long lasting coverage and protection of the eye
surface. Celluvisc is available in single use, preservative-free
containers.

f. GenTeal Lubricant Eye Gel (Ciba Vision). This is a clear gel
that liquefies upon contact with the eye, spreading rapidly without
leaving streaks or causing blurred vision. This gel is also
preservative free -- it contains a unique preservative that turns
into pure water and oxygen upon contact with the eye. Once in the
eye, this gel forms a long-lasting protective film. This is an
excellent choice for moderate to severe dry eye sufferers.



3. Oral Antibiotics:

Oral antibiotics are very effective at reducing ocular rosacea
symptoms. Oral antibiotics have several important actions in the
treatment of ocular rosacea:

• They stabilize the tear film.

• They improve oil secretion from meibomian glands.

• They decrease eyelid inflammation.

• They reduce eyelid bumps (chalazia and styes).

• They decrease the leakage of inflammatory cells through blood
vessels of the eye.

• They decrease eye surface flushing and inflammation (for some
unknown reason, antibiotics are quite effective against the vascular
symptoms of the eye).

a. Tetracycline Antibiotics. Oral tetracycline is very effective at
reducing the symptoms of ocular rosacea. Systemic tetracyclines
decrease eye surface inflammation, improve meibomian gland oil
secretion, improve the stability of the tear film layer, reduce
aqueous tear film evaporation, and improve the health of the ocular
surface. In most cases, symptom improvement is noted within 4 weeks
of treatment (250 milligrams 4 times a day).

b. Doxycycline. Ophthalmologists treat many of their ocular
rosacea patients with doxycycline due to its anti-inflammatory
actions and its positive effect on meibomian glands. Doxycycline
(50 or 100 milligrams 2 times a day) is very effective at reducing
ocular rosacea symptoms, and in some cases may be more effective
than standard tetracyclines.



4. Nutritional Therapy:

The main action of nutritional therapy is to reduce ocular
inflammation. Excess free radicals on the eye surface can cause eye
inflammation by dilating surface blood vessels and disrupting the
tear film layer. Increased oral intake of free radical scavengers
(antioxidants) may play a role in decreasing eye surface
inflammation and preventing damage to surface blood vessels:



(a) Antioxidants that have Anti-Inflammatory Actions in the Eye:

• Ester-C: Ester C is a form of vitamin C that is gentle on the
stomach and highly bioavailable. It is recommended that rosacea
sufferers slowly work their way up to 1,000 to 3,000 milligrams per
day (in divided doses).

• Grape Seed Extract: Grape seed extract is one of the most powerful
antioxidants known to science. It is recommended that rosacea
sufferers slowly work their way up to 150 to 300 milligrams per day
(in divided doses).

• Pycnogenol (pik-no-gen-ol): Pycnogenol has very similar actions to
grape seed extract. It is recommended that rosacea sufferers slowly
work their way up to 50 to 200 milligrams per day (in divided
doses).



(b) Essential Fatty Oils:

• Borage Seed Oil: Supplementation with essential fatty oils such
as gamma linolenic acid, the active ingredient in borage seed oil,
may be beneficial to patients with ocular symptoms. Gamma linolenic
acid (GLA) has two interesting mechanisms of action in the
treatment of ocular disorders: (1) GLA supplementation decreases
ocular inflammation, and (2) GLA supplementation increases mucous
production from goblet cells, resulting in a more stable tear film
layer.



5. Eliminate Eye Irritants:

Rosacea sufferers should be extra cautious when using products
around the eye area because they can cause allergic/irritant
reactions that may trigger ocular rosacea symptoms. Eye makeup,
eyeliners, mascara, under-eye concealers, and cleansers are common
triggers for eye irritation. Sunscreens and moisturizers (that run
down into the eye) can also irritate the ocular surface.



Hair sprays are problematic for many rosacea sufferers; the hair
spray mist can fall onto the eye surface and disrupt the tear film
layer. Eye experts emphasize that this is one of the worst ocular
irritants for female rosacea sufferers. It is highly recommended
that rosacea sufferers place a wide barrier, such as a hand-held
mirror, between the hairline and eyes before applying hair spray
(placing a hand over the eyes is usually not a sufficient barrier).
Otherwise, many unsuspecting rosacea sufferers are starting off the
day with a disrupted tear film layer and ocular irritation!



Extreme caution must also be given to "Get the Red Out" eye drops
that temporarily constrict blood vessels on the surface of the eye.
These eye drops should not be used by rosacea sufferers because
after the eye drop wears off, surface blood vessels usually become
more dilated and hyper-responsive. Over time, this makes the ocular
condition much worse.




STEP 3: ADVANCED OCULAR THERAPY


Ocular rosacea sufferers who do not respond adequately to basic
therapy (or continue to worsen), will need more advanced therapy.
Topical antibiotics, topical steroids, topical mast cell
stabilizers, oral isotretinoin, oral antifungals, punctal occlusion,
and photoderm offer moderate to severe ocular sufferers greater
chances for clearance.



1. Advanced Rosacea Therapy – First Tier:



(a) Antibacterial Eye Drops and Ointments:

Some rosacea sufferers have an overabundance of bacteria on their
eyelids. In ocular rosacea sufferers with bacterial infection,
topical antibiotics may help decrease ocular symptoms. Three popular
antibiotic eye drops and ointments are:

• Bacitracin Ophthalmic Ointment (Fougera)

• Ilotycin Ointment (0.5% Erythromycin, Lilly Research Laboratories)

• Polytrim Eye Drops (Trimethoprim and Polymyxin B Sulfate,
Allergan)




(b) Steroid/Antibacterial Eye Drops:

Topical steroids should not be used to treat most sufferers with
facial or ocular rosacea. However, in some cases, short courses of
topical steroids may give considerable relief to ocular symptoms and
may help break the vicious inflammatory cycle that often accompanies
ocular rosacea. Topical steroids applied to the eye surface and/or
eyelid margin can suppress inflammation and reduce the disease to a
level that is controllable with standard "safe" therapies. Most
eye experts who use topical steroids to treat ocular rosacea use a
three-day treatment plan to break the inflammation (i.e. steroid
treatment is prescribed two to four times per day for three
consecutive days). This is followed by a 21 to 28 day break from
the steroid. Three of the top steroid/antibacterial combinations are:

• Blephamide Liquifilm (10% sodium sulfacetamide + 0.2%
prednisolone acetate in a microfine suspension; Alcon Laboratories,
Inc.). This steroid/antibacterial liquifilm drop is extremely
effective against eye surface symptoms (inflammation, redness,
hypersensitivity and burning), and eyelid symptoms (inflammation,
swelling, crusting, itching and seborrheic dermatitis). Personal
communication with over a dozen ophthalmologists indicates that this
is one of the most effective topicals for the treatment of eye
surface and eyelid inflammation.
Blephamide liquifilm may be applied via two methods:


Method 1: Treatment of the Eye Surface and Eyelid

(1) Tilt head back and apply 1 drop into the eye.

(2) Close the eye and spread excess medication over the full length
of the upper and lower eyelids.

(3) Do not wipe any medication off the eyelids. It will dry
completely within 5 minutes to a clear film that remains on the lids
for several hours – it cannot be seen by others, nor will it
interfere with vision.




Method 2: Treatment of the Eyelid

(1) Tilt head back and with eye closed, place 1 drop onto the lid –
preferably in the corner of the eye close to the nose.

(2) Spread medication over the full length of the upper and lower
lids.



• Tobradex (tobramycin and dexamethasone opthalmic suspension;
Alcon Laboratories Inc.). This is an excellent steroid/antibacterial
drop that is used to treat eye surface and eyelid inflammation.

• Cortisporin (neomycin, polymyxin B sulfate and 1% hydrocortisone;
Catalytica Pharmaceutical, Inc). This is an excellent
steroid/antibacterial drop that contains a very weak steroid. It is
a good option for eyelids and eye surfaces that are sensitive to
strong steroids.



(c) Mast Cell Stabilizer Eye Drops:

Mast cell stabilizer eye drops prevent the release of inflammatory
substances from mast cells on the eye surface. Mast cell stabilizer
eye drops may decrease ocular rosacea symptoms by two different
mechanisms; they decrease allergy-related eye inflammation, and
reduce chronic inflammation on the eye surface.
Patanol (olopatadine HCL, Alcon Laboratories, Inc). Patanol has
two mechanisms of action; it blocks histamine receptors and
stabilizes mast cells on the eye surface. This blocks the
inflammatory actions of histamine, and prevents the release of half-
a-dozen potent dilators from mast cells. Patanol is one of the
newest topical eye drops that only requires twice daily dosing (one
dose lasts up to 10 hours). More importantly, Patanol starts to work
within minutes of application (unlike most other mast cell
stabilizers that require 4 to 7 days of dosing before they become
effective). Patanol is now considered to be the "gold standard" for
stabilizing mast cells on the eye surface.



(d) Very-Low-Dose Isotretinoin:

In ocular rosacea sufferers with severe eyelid inflammation, eye
surface inflammation, blocked meibomian glands, thick oil discharge,
or recurrent chalazions, very-low-dose isotretinoin usually results
in excellent clearance of symptoms.

Oral isotretinoin has several important actions in the treatment of
ocular rosacea:

• It decreases eyelid inflammation and swelling.

• It unblocks meibomian glands and normalizes thick oil discharge
from these glands.

• It decreases eye surface inflammation by blocking the production
of inflammatory immune cells.

• It treats chalazions and prevents future formation of these
eyelid bumps.

Note: For isotretinoin to be effective in treating ocular rosacea,
it must be used at very-low dosages (10, 5, or 2.5 milligrams per
day). Higher dosages, especially those used for acne, may have the
opposite effect and worsen ocular symptoms.




(e) Oral Antifungals:

Moderate to severe ocular rosacea sufferers with seborrheic
dermatitis may never truly get a hold on their ocular symptoms. In
these sufferers, medical experts recommend taking swabs of the outer
eyelids to examine for fungal infections. Personal reports from
numerous eye specialists indicate that in cases with seborrheic
dermatitis of the eyelids, short courses with oral antifungals can
be a Godsend in reducing ocular rosacea.


The goal of oral antifungal therapy is to decrease seborrheic
dermatitis down to levels that can be maintained easily with daily
lid hygiene and/or intermittent use of topical eye drops such as
blephamide. Three popular oral antifungals are:

• Ketoconazole (Nizoral Tablets, Janssen)

• Fluconazole (Diflucan Tablets, Pfizer)

• Itraconazole (Sporanox Capsules, Janssen)


2. Advanced Rosacea Therapy – Second Tier:

(a) Punctal Occlusion: Artificial tears are the most common therapy
used for dry eyes. Artificial tears are available for the relief of
symptoms but, unfortunately, improvement is short-lived because the
tears drain through the canals in the sides of the eyelids (puncta).
Conserving the eye's own tears is another approach to keeping the
eyes moist and comfortable. An ophthalmologist can conserve natural
tears by closing the canals via punctal occlusion. This is analogous
to plugging up a bathtub with a stopper; the closure conserves your
own tears and makes artificial tears last longer. Punctal occlusion
is usually considered when artificial tears and systemic medications
do not adequately control symptoms of dry eye, or when eye drops
have to be used very frequently. Punctal occlusion usually results
in dramatic relief of moderate to severe dry eye symptoms.



Benefits of punctal occlusion:

• It improves the tear film layer by increasing the aqueous
component of tear film.

• It improves the tear film layer by normalizing tear film
osmolarity.

• It improves the tear film layer by increasing the number of
mucous-producing goblet cells on the ocular surface.



Punctal Occlusion by Electrocautery. Electrocautery is the most
common method used to permanently close the canals. A fine, needle-
type cautery is inserted into the canals and seals them shut with
gentle heat. To test if punctal occlusion will result in epiphora
(a side effect where tears overflow from the eyes), eye specialists
first touch the cautery against the outer edges of the canal in
order to cause a thin scab to form over the opening. This scab
usually lasts for 5 to 7 days and during this time the physician
checks for adverse side effects. If the patient responds favorably,
he or she can proceed with permanent punctal occlusion (i.e., the
cautery tip is placed deep within the puncta and heat is then used
to seal the entire canal). Electrocautery is considered to be the
best method for permanent closure of the canals.


Punctal Occlusion by Silicone Plugs. Physicians also offer
reversible methods for blocking the drainage canals. Silicone plugs
can be used temporarily to plug the canals. These plugs give very
good results for several years and can be taken out at any time. The
Freeman silicone plug is currently the most popular brand among
ophthalmologists.


It must be warned that there are two main drawbacks to silicone
plugs (or any other form of insertable plug). First, some plugs may
cause irritation to the eyelid and/or slide deep into the canal and
cause a local irritant reaction. Second, silicone plugs can pop out
within 3 to 12 months.


Important Note on Punctal Occlusion: Inflammation of the eyelid and
eye surface must be under control before punctal occlusion is
performed or else inflammatory substances will stay on the eye
surface for longer periods of time, resulting in more inflammation.
(b) Photoderm Treatment: Photoderm (ESC Medical Systems) is an
intense pulsed light source that treats blood vessels of different
sizes, shapes, thicknesses, and skin depths. Recent advances in
Photoderm technology allow the system to safely remove inflamed
blood vessels of the eyelids (note: metal shields must be placed
between the eye surface and the eyelid before treatment to protect
the eye). Eyelid treatment should only be performed by photoderm
experts who have extensive experience with this form of vascular
treatment. Patients should not be guinea pigs for well-meaning, but
inexperienced practitioners.


Photoderm can effectively remove damaged blood vessels of the
eyelid, decrease flushing responses in the eye area, and reduce
eyelid swelling (a very difficult symptom to treat by standard
therapies). Photoderm may also normalize meibomian gland function
by decreasing eyelid vascularity and flushing which have been
implicated in meibomian gland dysfunction.


Hope this helps some,

Geoffrey
______________________________

Dr. Geoffrey Nase
Ph.D. Neurovascular Physiologist
http://www.drnase.com
______________________________