Ocular Rosacea: Dr. Eric Jones, MD

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Devers Eye Institute in Portland, Oregon, deals with advanced eye problems. On behalf of the RS group, Artist Cloutier recently met with Dr. Eric Jones, MD, the Medical Director of the institute, to discuss some of the questions on ocular rosacea posed by our members.

In preparation for the meeting, Dr Jones had discussed many of the questions with Linda, the librarian at the Merrill Reeh Ophthalmology Library, a regionally-renowned facility located on the Legacy Good Samaritan Hospital campus in Portland. Linda gave him 14 studies on ocular rosacea to pass on to us. Artist said: "Dr. Jones was very knowledgeable and helpful. I was delighted, to say the least! I will look at the studies Linda so kindly hunted out for us and will post interesting tidbits to the group."

Here is the transcript of their meeting:

Q: Is it safe to use steroids on an occasional basis to calm the eyes, or is there something non-steroidal that can decrease redness?

A: The indications for steroids and ocular rosacea are pretty specific, usually related to iritis in ocular rosacea patients. They can also get scleritis, which the steroids can treat. For just decreasing the redness, I don't think it's recommended for that. To decrease the redness, you know about lasers, but ... hygiene, tetracycline, overall treatment for the underlying problem should help.

Q: Is it typical for ocular rosacea to be at its worst first thing in the morning?

A: We looked that up, time of day, time of year. We didn't find that. It can be different for different people. We did find one study indicating it can be worse in the spring.

Q: If hot compresses are making the eyes more bloodshot and aggravating facial flushing, would it be better not to use compresses?

A: You are talking about relief of symptoms. The idea behind the warm compresses is dilating the glands that are blocked off. Anything you can do to dilate the glands and help the natural oil lubricate the eye better is going to decrease the eye symptoms. While it does dilate the blood vessels also, which can make the telangiectasia and erythema worse, the idea is to relieve the plugged glands, get those oils that are clogged up flowing again. It may feel worse in the short term, but it will be better overall once you get those glands flowing.

Q: Are cotton balls acceptable instead of Q-tips and Ocuscrub pads?

A: Yes

Q: What are the top 3 brands of moisturizing eye drops you would recommend for ocular rosacea?

A: Preservative-free artificial tears, whatever brand it is, are probably the best. There are so many brands out there, Sustain and Refresh... Those are the cadillacs, preservative-free. The ones with preservatives can cause irritation with chronic use, especially more than 4 or 5 times a day. Visine makes a good one, but not the one that "gets the red out" because that has steroids in it.

Q: How long can one safely use drops such as Tobradex, Vigamox, Patanol?

A: Tobradex is a combo of antibiotic and steroid. Anyone on that needs to have regular eye pressure checks because the steroid component of any drop can lead to increased eye pressure which can lead to glaucoma possibly, can also cause cataracts. They should have their eye pressure checked usually if they are on it within a few weeks. Vigamox is strictly an antibiotic, so it's really not indicated for long term use. We usually use it to treat acute infection, just for 7-14 days. Patanol is an anti-allergy drop which can be used for extended periods of time. It doesn't have steroids in it. It's typically … well, some people may be on it continually, especially when allergies are worse, during spring and what-not.

Q: Do you agree with the view that Restasis won't help ocular rosacea or dry eye triggered by Accutane?

A: The drug rep was in for Restasis the other day and I asked her about it. We looked it up here and didn't find any studies that checked on Restasis and ocular rosacea together. It's a great question because, you know people with ocular rosacea have decreased tear production and, if Restasis can help that, I don't see why it wouldn't work.

Q: Is there any danger in scratching off blepharitis bumps on the inside edge of the eyelid, or are there any drops to treat them?

A: You know, what those bumps are referring to are the plugged meibomian glands .. the little white bumps. That's the plugged up oil glands that need to start flowing again. So, warm compresses, lid hygiene, lid scrubs can help break those up. As far as sticking your fingernail in there and scraping them off, I probably would not recommend that. I would just recommend the lid hygiene protocol.

Q: Is there any way of improving the appearance of sparse lashes, or of reversing thickened eyelids (eg IPL)?

A: Outside of just the treatment of ocular rosacea in general, I'm not aware of any. There are cosmetic things as far as sparsity, such as false eyelashes and makeup and tattooing, which I really don't know if they can even aggravate it. You know, if you have a prosthesis there, fake lashes, or makeup, it might aggravate the ocular rosacea. Laser, for thickened eyelids ... I'm not sure about the thickening but for general erythema and telangiectasia it's supposed to be very effective.

For people with ocular rosacea, if blepharitis and inflamed oil glands have been brought under control:

Q: Is it all right to use contact lenses (for how many hours a day?)
A: Yes. There are many levels of ocular rosacea, mild to severe. Everyone has to go on an individual basis as to whether or not they can, but yes in mild cases I would say so.
Q: Is it all right to use eye makeup (any recommended brands? or would permanent eyeliner be safer?)
A: I don't know of any studies. People need to know their own triggers and if it gets worse, stop and try another brand.

Q: Will flickering/twitching eyes lead on to ocular rosacea, or are they perhaps an indication that ocular rosacea is starting?

A: I don't know that flickering/twitching eyes are involved. I have not heard that. Ocular rosacea leads to corneal surface irritation often times and that can lead to blinking and what-not, as if you had sand in your eye. So, it's possible.

Q: Are closed tear ducts that require the implantation of stents likely to lead to ocular rosacea, or are they not even related to it?

A: I am guessing they are talking about nasolacrimal duct obstruction, which is the duct that connects the eye to the nose, where your tears naturally drain from your eye to the nose. We looked it up and did not find anything. It could be ... you know, is it possible that an inflammatory process in the eye could cause inflammation in the duct, which would lead to that duct being closed off a little bit, which is what happens when you put a stent in … It's not unreasonable, but I can't quote any studies.

Q: Can Lasik surgery trigger ocular rosacea, and is Lasik surgery ever safe for rosaceans?

A: In general, dry eyes are a contraindication for Lasik. So, if someone has surface disease you would want to have that under excellent control. And, depending on the severity of it, you may not want to have Lasik at all. It goes on an individual basis.

Q: Do you think IPL treatment of the face usually improves ocular rosacea? What about patients who feel that IPL has made their ocular rosacea worse?

A: What I've read about it is that, usually it's about 80 percent improvement. I haven't known anybody where it makes it worse. I found one study in here - one case report, rather - where there was an adverse effect with blistering and what-not.

Q: Is telangiectasia of the eyeball permanent, or can lasers or some other treatment remove them?

A: Telangiectasia of the eye itself? I would guess that is reversible. Whether or not that is really telangiectasia I'm not sure, or if it's just the episcleritis, scleritis, the inflammatory process of the eye itself on the conjunctiva .. basic conjunctivitis, which causes the white part of the eye to become very red, which could be reversed with treatments. So I don't know if those are the same etiology as the telangiectasia of the skin.

Q: What role do you feel nutrition plays in treating ocular rosacea, and are there any foods to stay away from that could trigger the eyes?

A: There are studies with just dry eye, where flaxseed oil and omega 3s are quite effective. Foodwise, everyone is individual. There have been some surveys, and everyone was different. Some said spicy foods, others said hot drinks, alcohol, cold drinks. People have to find their individual triggers, I think.

Q: Will drinking at least 64 oz of pure water daily decrease the symptoms of ocular rosacea?

A: All I can say is drinking a lot of water is good for you in general. Probably keeps you hydrated and if you do have a tendency toward dry eye, it may help that. We looked for studies and there were none related to drinking water and ocular rosacea.

Q: The main supplements our members are taking are Ester C, Grape Seed Extract, Pycnogenol and GLA. Are there any other supplements on a par with GLA? Do you favour fish oil or flaxseed oil?

A: I know of no hard studies for the GLA. The flaxseed oil and omega 3s are the only thing that I know of that help.

Q: For people in other towns, have you any advice on how to find an eye specialist who understands ocular rosacea?

A: In a bigger city, there are always universities and teaching institutions like Dever's and OHSU. In smaller towns, you know, this is definitely part of our training. I mean, it's something an ophthalmologist should know about. There will always be varying degrees, people knowing more or less. I'd say educating themselves like, say, through your group would be a very good thing to do.

Q: What basic routine do you recommend, eg scrubs, drops, nutritional therapy, laser treatments, antibiotics? (If possible, it would be good to have an idea of recommended strengths, and for how long they can be used; eg how long can one stay on Doxycycline?)

A: I usually start out, like with how most chronic problems start, with just the basics of lid hygiene and artificial tears and taking care of the surface, but depending on the severity of it. If someone comes in with just severe ocular rosacea, I'll start them on an antibiotic right away. If that's not improving their symptoms, then I'll go on to an oral antibiotic - usually Doxycycline, which is 100mg twice a day. The real, initial studies were done on Tetracycline. But the evidence, as far as what doctors like, Doxycycline works just as well, maybe with less side effects as far as stomach upset and what-not. You know you can have photo-sensitivity, diarrhea and stomach problems. So it's not something I want to put somebody on right away for a mild case necessarily. Usually they are put on it for about a month to start with, and then taper off it very slowly to whatever ... then, if it comes back, you can bump it up again. Some people are on it indefinitely, but it's rare. Most people you can taper off it. If they are on it indefinitely, they are on a very low dose.

Artist thanked Dr. Jones on behalf of the group and explained that the information he had provided would be made available on our web site and would help many people. Dr. Jones expressed his pleasure at being able to help. He wanted to encourage patients also to use the Merrill Reeh Ophthalmology Library, which is the only ophthalmology library in the Pacific Northwest that is open to the public and clinicians alike. The library houses the region's most complete collection of ophthalmologic journals and patient education materials and includes books, videos, journals, slides, and pamphlets.

Devers Eye Institute

To contact the library, please call 503-413-7678. Linda, the librarian, is very helpful. If you are in the Portland area, Linda will help look up studies with you.

For more information on Ocular Rosacea, checkout Ocular Rosacea Articles for the latest research and information available.