Ocular Rosacea Research Articles

Severe ocular manifestations of rosacea in adult

PurposeOcular rosacea in adult is a rare condition that may be responsible for palpebral, cunjonctival and corneal complications with severe visual functional prognosis in some cases. The purpose of this study is to determine the nature and prognosis of corneal complications in this disease through our study and literature reviewMethodsWe report seven patients (14 eyes) with severe ocular rosacea requiring hospitalization.ResultsThe mean age of our patients was 59.6 years. Six patients (85.6%) were female. Visual acuity was <1/10 in 10 eyes. The complications were keratitis in 7 eyes, corneal ulcerations in 5 eyes, corneal perforation in 5 eyes, and catarrhal infiltrates in 6 eyes. Limbal neovascularization was noted in 11 eyes. Only one patient has ocular‐cutaneous form. All patients were treated with oral cycline, topical steroids in acute phase, artificial tears and eyelid hygiene. A bandage contact lens was applied to 4 eyes. Three eyes required penetrating keratoplasty. They were successfully treated with improvement of symptoms and cicatrisation of corneal lesions. One case of corneal graft failed secondary to infectious keratitis.ConclusionsThe diagnosis of ocular rosacea is difficult because it often occurs without skin involvement. Ocular rosacea is the only complication of cutaneous rosacea. Diagnosis should be as early as possible because ocular complications are possible, with blinding potential. The best treatment is prevention with regular eyelid hygiene.

In vivo confocal microscopy evaluation of ocular and cutaneous alterations in patients with rosacea.

The physiopathology of rosacea and the correlation between ocular and cutaneous rosacea remains unclear. This study analysed ocular and cutaneous rosacea with in vivo confocal microscopy (IVCM). Thirty-four eyes of 34 patients with confirmed rosacea-associated meibomian gland dysfunction-related evaporative dry eye were enrolled in the study. The ophthalmological investigations included dry eye ocular surface disease index (OSDI), the Schirmer test, tear osmolarity, tear break up time, the Oxford score, infrared meibography for meibomian gland (MG) analysis and IVCM investigation for cornea, MG and skin analysis (cheek, hand). Presences of Demodex in the MG and in the cheek were also investigated. We established scores for quantifying the MG alterations in the MG (IVCM-MG) and cheek (IVCM-Cheek), and scores for Demodex quantification in the MG and cheek (IVCM-MG-Dex and IVCM-Cheek-Dex). IVCM was relevant for analysing the cornea and MG structures and was also suitable for cutaneous analysis. Exposed skin explorations presented the epidermal and dermal layers clearly. In patients with rosacea, the IVCM-MG alteration scores were correlated with IVCM-Cheek (R2=0.27 and p=0.0006) and IVCM-MG-Dex was correlated with IVCM-Cheek-Dex (R2=0.70 and p<0.0001). However, no correlation was found between the IVCM-MG or IVCM-Cheek and the break up time, Schirmer, Oxford and osmolarity evaluations. IVCM could be a safe, effective and reliable tool to quantify alterations of the cornea, MG and cheek glands in patients with rosacea combined with quantification of Demodex infections. As a valuable tool for investigating the pathophysiology of the disease, it could be used to assess the effectiveness of therapy.

Exploring the Association Between Rosacea and Parkinson Disease: A Danish Nationwide Cohort Study.

The pathogenesis of rosacea is unclear, but increased matrix metalloproteinase target tissue activity appears to play an important role. Parkinson disease and other neurodegenerative disorders also display increased matrix metalloproteinase activity that contribute to neuronal loss. To investigate the risk of incident (new-onset) Parkinson disease in patients with rosacea. A nationwide cohort study of the Danish population was conducted using individual-level linkage of administrative registers. All Danish citizens 18 years or older from January 1, 1997, to December 31, 2011 (N = 5 472 745), were included. Data analysis was conducted from June 26 to July 27, 2015. The main outcome was a diagnosis of Parkinson disease. Incidence rates (IRs) per 10 000 person-years were calculated, and incidence rate ratios (IRRs) adjusted for age, sex, socioeconomic status, smoking, alcohol abuse, medication, and comorbidity were estimated by Poisson regression models. A total of 5 404 692 individuals were included in the reference population; of these, 22 387 individuals (9812 [43.8%] women; mean [SD] age at diagnosis, 75.9 [10.2] years) received a diagnosis of Parkinson disease during the study period and 68 053 individuals (45 712 [67.2%] women; mean age, 42.2 [16.5] years) were registered as having rosacea. The IRs of Parkinson disease per 10 000 person-years were 3.54 (95% CI, 3.49-3.59) in the reference population and 7.62 (95% CI, 6.78-8.57) in patients with rosacea. The adjusted IRR of Parkinson disease was 1.71 (95%, CI 1.52-1.92) in patients with rosacea compared with the reference population. There was a 2-fold increased risk of Parkinson disease in patients classified as having ocular rosacea (adjusted IRR, 2.03 [95% CI, 1.67-2.48]), and tetracycline therapy appeared to reduce the risk of Parkinson disease (adjusted IRR, 0.98 [95% CI, 0.97-0.99]). Rosacea constitutes an independent risk factor for Parkinson disease. This association could be due to shared pathogenic mechanisms involving elevated matrix metalloproteinase activity. The clinical consequences of this association require further study.

Ocular response analyser measurements and central corneal thickness in ocular rosacea patients.

Rosacea is a chronic cutaneous disorder which is known to cause inflammation and increased proteolytic activity on the ocular surface that might lead to corneal biomechanical alterations. The aim of this study is to evaluate the corneal biomechanical properties of ocular rosacea patients and compare the measurements with healthy individuals as measured with Reichert ocular response analyser (ORA). Besides full eye examination [best corrected visual acuity (BCVA), intraocular pressure (IOP) measured with Goldmann applanation tonometry (IOP-G)], central corneal thickness (CCT), and ORA [corneal hysteresis (CH), corneal resistance factor (CRF), corneal compensated IOP (IOPcc), Goldmann correlated IOP (IOPg)] measurements of 30 eyes of 15 ocular rosacea patients (study group) and 30 eyes of 15 healthy individuals (control group) were performed. For comparisons paired t test was used. Mean age of study group was 45.26±11.65 (range 25 and 63) and control group was 45.00±8.91 (range 26 and 58) years (p=0.865). No significant difference in BCVA, CCT, IOP-G, IOPcc was detected among groups. However, IOPg, CH, and CRF in the study group were significantly lower than in the control group (p=0.013, p=0.013, p=0.009, respectively). IOPg, CH, and CRF parameters of ocular rosacea patients were significantly lower than normal individuals. These differences and their probable clinical reflections that might effect making decisions in conditions such as glaucoma should be investigated in larger number of patients.

Clinical Findings, Follow-up and Treatment Results in Patients with Ocular Rosacea

Objectives:To report the clinical features, treatment options and complications in patients with ocular rosacea.Materials and Methods:The records of 48 eyes of 24 patients with ocular rosacea were retrospectively reviewed. Patients’ ocular signs and symptoms were scored between 1 and 4 points according to disease severity; tear film break-up time (BUT) and Schirmer’s test results were recorded before and after the treatment. Preservative-free artificial tears, topical antibiotic eye drops/ointments, short-term topical corticosteroids, topical 0.05% cyclosporine and oral doxycycline treatment were applied as a standard therapy to all patients. Additional treatments were given as needed. Complications were recorded.Results:Twenty-four patients with a mean age of 48.5±35.4 (32-54) years were followed for a mean 15±9.4 (8-36) months. Ocular findings included meibomitis in 100% of cases, anterior blepharitis in 83% (40 eyes), punctate keratopathy in 67% (32 eyes), chalazia in 50% (24 eyes), corneal neovascularization in 50% (24 eyes) and subepithelial infiltrates in 16.6% (8 eyes). Significant improvement of symptoms and clinical findings were achieved in all patients with treatment. The increases in Schirmer’s test and BUT were 3.3±1.5 and 4.5±2.8, respectively (p<0.05). Descemetocele and small corneal perforation occurred in 2 eyes; re-epithelialization was achieved in both eyes with tissue adhesive application (1 eye) and additional amniotic membrane transplantation (1 eye). Four eyes of three patients showed significant regression of corneal neovascularization with topical bevacizumab therapy.Conclusion:Ocular rosacea may present with a variety of ophthalmic signs. It is possible to control the ophthalmic disease with appropriate therapeutic modalities including topical corticosteroids, topical cyclosporine and systemic doxycycline.

Pediatric ocular rosacea, a misdiagnosed disease with high morbidity: Proposed diagnostic criteria

Pediatric ocular rosacea, a misdiagnosed disease with high morbidity: Proposed diagnostic criteria

Pathogenesis, clinical picture, and current therapy of rosacea

Rosacea is a common chronic inflammatory disease, especially in patients with fair skin and positive family history. Typical locations are forehead, nose, cheeks and chin; the periorbital region is usually not involved. Clinical features can be very heterogeneous. Besides different subtypes (erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea), which often overlap, various special forms of rosacea exist. Up to 60% of patients with cutaneous rosacea suffer from ocular rosacea. In Germany, brimonidine, metronidazol, azelaic acid, and ivermectin are approved for topical therapy of rosacea; for systemic therapy, doxycycline at a subantimicrobial dose (40 mg/day) is the only approved substance. In case of resistance to this therapy, contraindications or side effects, various alternative therapies are available, however off-label.

Interventions for Rosacea.

Which interventions are associated with highest efficacy and fewest adverse events for treating rosacea? There is high-quality evidence that topical brimonidine, azelaic acid, and ivermectin, as well as oral doxycycline and isotretinoin, are associated with improvements in rosacea. Lower-quality evidence is available for topical metronidazole, oral tetracycline, laser and light-based therapy, and topical cyclosporine for ocular rosacea. Most treatments are not associated with higher adverse event rates than placebo.

Morphological and Functional Evaluation of Meibomian Gland Dysfunction in Rosacea Patients

ABSTRACTPurpose: Skin rosacea is a chronic inflammatory disease affecting up to 10% of the population in some European countries. Although considered a skin disease, acne rosacea may involve the eyes, causing eyelid and ocular surface inflammation. This study investigated the relationship between skin rosacea and various signs of ocular involvement and evaluated severity of meibomian gland dysfunction in rosacea patients.Methods: The ocular surface and meibomian gland parameters were evaluated in 41 patients with diagnosed skin rosacea and 44 age-matched healthy controls. We analyzed meibomian gland function (meibum quality and meibum expressibility) and morphology (meibography) and lid margin alterations. We correlated our findings with self-reported ocular symptoms and tear film abnormalities (tear film breakup time, Schirmer test).Results: The prevalence of ocular erythema and lid margin alterations was significantly higher in rosacea patients compared with controls. We found that rosacea is accompanied with significant loss of meibomian gland tissue defined as reduced meibomian gland area and decreased meibomian gland density. A positive correlation between margin abnormality score and the extent of meibomian gland loss in rosacea group was observed (rs = +0.30, p = 0.005), suggesting that ocular rosacea is accompanied by meibomian gland dropout.Conclusion: Skin rosacea is associated with ocular erythema and lid margin abnormalities. Our results suggest that ocular signs of rosacea may influence meibomian gland morphology, causing meibomian gland loss.

Rosacea Blepharoconjunctivitis Treated with a Novel Preparation of Dilute Povidone Iodine and Dimethylsulfoxide: a Case Report and Review of the Literature.

IntroductionPovidone iodine (PVP-I) 10% aqueous solution is a commonly utilized anti-septic employed for sterilization of the ocular surface prior to interventional procedures. Dimethylsulfoxide (DMSO) is a well-known skin penetration agent scarcely utilized in ophthalmic drug formulations. We describe here a low-dose formulation of 1% PVP-I (w/w) in a gel containing DMSO for use in the setting of recalcitrant rosacea blepharoconjunctivitis. A review of the ocular uses of dimethylsulfoxide is also presented.Case reportA 78-year-old male presented with chronic, long-standing blepharitis involving both the anterior and posterior lid margins. Posterior lid and skin inflammatory changes were consistent with ocular rosacea. Previous oral and topical therapies had been largely ineffective at controlling his condition.ConclusionThe topical PVP-I/DMSO system was effective in abating the signs and symptoms of rosacea blepharoconjunctivitis. Further investigation of this novel agent is warranted.Electronic supplementary materialThe online version of this article (doi:10.1007/s40123-015-0040-4) contains supplementary material, which is available to authorized users.

Collyres de ciclosporine : étude d’une cohorte de patients de 2009 à 2013

The University Hospitals Paris Centre Pharmacy compounds three concentrations of cyclosporine eye drops: 20mg/mL (=2%); 5mg/mL (=0.5%) and 0.5mg/mL (=0.05%). Cyclosporine A 2% drops were developed in 1995 to prevent the rejection of high-risk cornea transplants after failure of topical steroids. The other concentrations of eye drops were developed for the treatment of various immune or inflammatory diseases of the cornea, conjunctiva and uvea. These eye drops are dispensed with a physician's prescription to hospitalized or ambulatory patients. A retrospective study over 4 years (2009-2013) was conducted to analyze the details of prescription and possible adverse events. Dispensations made from January 1st, 2009 through December 31st, 2013 were studied, including patient age, dose of cyclosporine and practice location of prescribing physician. We also recorded the indications for cyclosporine eye drops in a sample of ambulatory patients. The analysis of local tolerability and the effect on visual comfort was based on questionnaires sent to the patients on cyclosporine 2% over a period of 2 months. Cyclosporine eye drops prescription grew continuously from 2009 through 2013 for all concentrations. In 2013, 5,859 patients were treated, among which 3,616 patients with topical cyclosporine 2%, 1,681 patients with 0.5%, and 562 patients with 0.05%. In total, this represents 62,621 eye drops. Treated patients ranged from 1 week to 100 years old. Topical 2% cyclosporine is indicated in 61% of cases to prevent high-risk corneal graft rejection. Other indications are corneal ulcer (6%), atopic keratoconjunctivitis (5%), vernal keratoconjunctivitis (5%) and herpetic keratitis (4%). Topical 0.5% cyclosporine is prescribed primarily for dry eye syndrome (20%) and to prevent rejection of high-risk corneal transplantation (11%), to treat ocular rosacea (10%), vernal keratoconjunctivitis (10%), atopic keratoconjunctivitis (8%) and Sjögren's syndrome (7%). Topical 0.05% cyclosporine is prescribed primarily for dry eye syndrome resistant to conventional treatment (47%) and Sjögren's syndrome (21%). Local tolerability of topical cyclosporine was evaluated in 388 patients. The majority of patients (63%) did not experience any adverse effects. The main side effects are redness, burning sensation and itching. Prescription of various formulations of topical cyclosporine is current practice for surgical indications: rejection of high-risk corneal transplantation; or medical indications: vernal or atopic keratoconjunctivitis and dry eye syndrome. Further prospective randomized studies would be necessary to validate formulations, doses and indications of cyclosporine eye drops.

Interventions for rosacea: abridged updated Cochrane systematic review including GRADE assessments.

Rosacea is a common chronic facial dermatosis. This update of our Cochrane review on interventions for rosacea summarizes the evidence, including Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group assessments, of the effects of the currently available treatments. Searches included the following: Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE, EMBASE, LILACS and the Science Citation Index, and ongoing trials registries (July 2014). We included 106 randomized controlled trials (RCTs) with 13631 participants, a more than 80% increase since the last update in 2011. Pooling of data was feasible for a few outcomes, for topical metronidazole and azelaic acid and both appeared to be more effective than placebo (moderate and high-quality evidence, respectively). Topical ivermectin was more effective than placebo based on two studies (high-quality evidence), and slightly more effective than metronidazole in one study. Brimonidine was more effective than vehicle in reducing erythema in rosacea (high-quality evidence). Ciclosporin ophthalmic emulsion was effective for ocular rosacea (low-quality evidence). For oral treatments there was moderate-quality evidence for the effectiveness of tetracycline based on two old studies, and high-quality evidence for doxycycline 40mg compared with placebo according to physician assessments. One study at high risk of bias demonstrated equivalent effectiveness for azithromycin and doxycycline 100mg. Minocycline 45mg may be effective for papulopustular rosacea (low-quality evidence). Low-dose isotretinoin appeared to be slightly more effective than doxycycline 50-100mg (high-quality evidence). Laser and light-based therapies for erythema in rosacea were effective (low-quality evidence). Further RCTs are required for ocular rosacea.

Intense pulsed light therapy for the treatment of evaporative dry eye disease.

Evaporative dry eye disease is one of the most common types of dry eye. It is often the result of chronic meibomian gland dysfunction (MGD) and associated ocular rosacea. Evaporative dry eye and MGD significantly reduce patient's quality of life. Traditional treatments, such as artificial tears, warm compresses, and medications, such as topical cyclosporine, azithromycin, and oral doxycycline, provide some relief; however, many patients still suffer from dry eye symptoms. Intense pulsed light (IPL) therapy, which has been used extensively in dermatology to treat chronic skin conditions, is a relatively new treatment in ophthalmology for patients with evaporative dry eye disease. There are very few studies published on the use of IPL in patients with dry eye disease. The present review describes the theoretical mechanisms of IPL treatment of MGD and ocular rosacea. Personal clinical experience and recently presented data are reported as well. IPL therapy has promising results for evaporative dry eye patients. There are statistically significant improvements in clinical exam findings of dry eye disease. More importantly, patients report subjective improvement in their symptoms. More research is needed in this area to help understand the mechanism of dry eye disease and how it can be effectively treated.

Treatment of ocular rosacea: comparative study of topical cyclosporine and oral doxycycline.

To compare the effectiveness of topical cyclosporine A emulsion with that of oral doxycycline for rosacea associated ocular changes and dry eye complaints. One hundred and ten patients with rosacea were screened. Thirty-eight patients having rosacea associated eyelid and ocular surface changes and dry eye complaints were included in the study. Patients were randomly divided into two groups: nineteen patients were given topical cyclosporine twice daily and nineteen patients were given oral doxycycline 100 mg twice daily for the first month and once daily for the following two months. Symptom and sign scores, ocular surface disease index questionnarie and tear function tests were evaluated at baseline and monthly for 3mo. Three months after results were compared with that of baseline. Mean values of symptom, eyelid sign and corneal/conjunctival sign scores of each treatment group at baseline and 3mo after treatments were compared and both drugs were found to be effective on rosacea associated ocular changes (P<0.001). Cyclosporine was more effective in symptomatic relief and in the treatment of eyelid signs (P=0.01). There was statistically significant increase in the mean Schirmer score with anesthesia and tear break up time scores in the cyclosporine treatment group compared to the doxycycline treatment group (P<0.05). Cyclosporine as a topical drug can be used in the treatment of rosacea associated ocular complications because it is more effective than doxycycline. In addition ocular rosacea as a chronic disease requires long term treatment and doxycycline has various side effects limiting its long term usage.

Severe Facial Dermatitis Following Rhinoplasty due to an Unusual Etiopathogenesis: Rosacea.

Severe Facial Dermatitis Following Rhinoplasty due to an Unusual Etiopathogenesis: Rosacea.

Analysis of the role of Bacillus oleronius proteins in the induction of tissue damage and inflammation in ocular rosacea

Analysis of the role of Bacillus oleronius proteins in the induction of tissue damage and inflammation in ocular rosacea

Keratoconus: an inflammatory disorder?

Keratoconus has been classically defined as a progressive, non-inflammatory condition, which produces a thinning and steepening of the cornea. Its pathophysiological mechanisms have been investigated for a long time. Both genetic and environmental factors have been associated with the disease. Recent studies have shown a significant role of proteolytic enzymes, cytokines, and free radicals; therefore, although keratoconus does not meet all the classic criteria for an inflammatory disease, the lack of inflammation has been questioned. The majority of studies in the tears of patients with keratoconus have found increased levels of interleukin-6 (IL-6), tumor necrosis factor-α(TNF-α), and matrix metalloproteinase (MMP)-9. Eye rubbing, a proven risk factor for keratoconus, has been also shown recently to increase the tear levels of MMP-13, IL-6, and TNF-α. In the tear fluid of patients with ocular rosacea, IL-1α and MMP-9 have been reported to be significantly elevated, and cases of inferior corneal thinning, resembling keratoconus, have been reported. We performed a literature review of published biochemical changes in keratoconus that would support that this could be, at least in part, an inflammatory condition.

Interventions for rosacea.

Interventions for rosacea.

Topographic and biomechanical evaluation of corneas in patients with ocular rosacea.

To compare the topographic and biomechanical properties of corneas in the eyes of patients with ocular rosacea (OR) with those of healthy individuals. Thirty-four healthy individuals (control group) and 34 patients with OR (study group) were evaluated in this study. Topographic measurements including keratometry values, irregularity, and surface asymmetry index in the right eye of each participant were obtained using a Scheimpflug camera with a Placido disc topographer (Sirius). Corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOP), and Goldmann-related IOP were measured using the Reichert Ocular Response Analyzer. Central corneal thickness was also measured using ultrasonic pachymetry and the Sirius corneal topography system. Topographic parameters were not significantly different between the groups (P > 0.05). Mean CH and CRF were significantly lower in patients with OR (P = 0.003 and 0.001, respectively). Central corneal thickness was significantly lower in patients with OR compared with healthy controls (P < 0.001). Mean Goldmann-related IOP and corneal-compensated IOP were not significantly different between the groups (P = 0.09 and 0.13, respectively). This study demonstrated that although the eyes of patients with OR had corneal topographic findings similar to those of healthy controls, corneal biomechanical measurements (CH and CRF) were significantly lower in patients with OR. These results need to be considered when planning corneal refractive surgery in patients with OR.

Prevalence of rosacea in community settings.

The prevalence of rosacea is poorly characterized. Because selection bias may affect prevalence estimates, there is a need to characterize the prevalence of rosacea outside the clinic setting. To assess the prevalence of rosacea in community settings. A clinical research fellow and a medical student stood in public places (a mall, the Department of Motor Vehicles, a grocery store) and examined consecutive individuals who passed by ≤ 2 yards away. They tallied demographic and descriptive data on the subject and included the subject in one of three categories: clearly rosacea, possible rosacea, and definitely no rosacea. Subanalyses by perceived gender, age, race, and rosacea subtype were also performed. Comparisons between groups were made using the Fisher exact test. Considering the prevalence of rosacea among all observed individuals in the community setting, 5.4% (95% CI 3.6-7.8) of individuals had "possible" rosacea and 6% (95% CI 4.1-8.5) of individuals had "definite" rosacea. Older, white individuals with fairer skin types (Fitzpatrick skin types I, II, and III) were more likely to have rosacea. There was no gender predisposition. Distance from subjects made it difficult to assess patients with mild rosacea or a few telangiectasias, as well as ocular rosacea. The study could not assess those individuals who were too embarrassed by their rosacea to be in the public settings observed. Additionally, some subjects may have applied significant makeup in an effort to conceal their rosacea, making assessment difficult. Based on direct observation of individuals in community settings, rosacea is more common than previously reported in the United States.