Ocular Rosacea: Dr. Mark J. Mannis, MD

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Dr. Mark J. Mannis, MD, FACS, Professor and Chair, Department of Ophthalmology & Vision Science at the University of California, Davis, kindly answered questions on ocular rosacea in an interview with Artist Cloutier. Dr. Mannis has been an ophthalmologist for many years. He has authored more than 100 publications and books on topics relating to corneal surgery and disease, and has recently published several peer-reviewed articles on ocular rosacea. A PubMed search for Dr. Mannis shows 7 pages of results with 123 articles, 7 or so mentioning rosacea in the title.

The Support group would like to express our deepest thanks to Dr. Mannis for his help, and also to his assistant Roberto, who was invaluable in arranging the interview. Thanks also to Artist for conducting and transcribing the session.

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

A: Telangiectasias really are an expression of the degree of inflammation, and over time with chronic inflammation the changes do become permanent. They really are not amenable to treatment with laser therapy because that would potentially damage the lid, which is an extremely important functional part of the eye. So, the key is, if patients who actually have telangiectasia on the lid can be treated early enough, then the likelihood is that the architectural changes can be reversed before they are permanent.

Q: Do you think IPL treatment of the face usually improves ocular rosacea? What about patients who feel that it has made their ocular rosacea worse, eg more veins showing in the white of the eye, lids more sensitive, eyelashes falling out, hot compresses now cause the eyes to swell?

A: Unfortunately, as ophthalmologists, we have very little experience with IPL. That's something that's done by and large by dermatologists. I am not aware of any definite ocular side effects from facial treatments with IPL.

Q: Does ocular rosacea increase the likelihood of cataracts or other eye diseases such as macular degeneration, or central serrous corinopathy (retinopathy)?

A: No. But, if IPL is done, there needs to be eye protection. Any kind of laser treatment done on the skin around the eye requires the practitioner to use eye shields to be sure that the globe is not exposed to the intense light in any way. As long as it's not, then the likelihood of any of those problems occurring is very small.

Q: Any thoughts on what can be done to prevent progression of ordinary rosacea into the ocular form?

A: Obviously, good systemic control of the disease with agents such as tetracycline or doxycycline is really very important. That will largely prevent the extension to ocular rosacea. Unfortunately 20% of patients with ocular rosacea present without the skin findings, so that sometimes ocular rosacea can be the first manifestation of the disease. But, in general, the principle holds that if there is adequate systemic treatment for rosacea, the likelihood of their developing significant ocular rosacea is very small.

Q: What role do you feel nutrition plays in treating ocular rosacea?

A: Actually, the only significant information that we have about nutrition is that a switch in the diet from a predominance of omega 6 fatty acids to omega 3 fatty acids will help the inflammation around the eye and will increase the ocular hydration. So, it's a good idea for patients to either consider using dietary supplements that are high in omega 3 fatty acids or to increase the component of their diet that includes fish oil, and those things will help to decrease the eye inflammation.

Q: Why is it so hard for some ophthalmologists to recognize ocular rosacea? Aren't there any medical tests to verify this diagnosis? What ocular symptoms most commonly suggest that ocular rosacea is present?

A: Well, the most common ocular symptom is the sensation of burning and redness of the white of the eye between the lids - a sort of 'racing stripe' on the front of the eye. These patients experience fairly significant burning and tearing sensations. Unfortunately there is no current test that clearly diagnoses ocular rosacea. Our lab has, for the last two years, been working on exactly that problem. We are investigating patients who have rosacea and analysing their tears for a variety of substances, including proteins, lipids, and mucopolyasaccharides. We're trying to find single substances which are present in rosacea patients, which are not present in either normal patients or in patients with other types of ocular inflammation. If we can demonstrate that there is a factor in the tears of rosacea patients that is distinct from other patients, then we will succeed in determining a specific diagnostic test. But at the present time, it's pretty much a clinical diagnosis based on history and clinical findings. We have been very fortunate that the NRS has given us a very generous grant...we are working on this very intensively.

Q: Have you any advice on how to find an eye specialist who understands ocular rosacea? If it isn't possible to find an ophthalmologist willing to discuss rosacea, would it be acceptable to ask a dermatologist to also treat the ocular rosacea?

A: First of all, any ophthalmologist who specialises in external eye disease (they are also referred to as cornea specialists), should be able to deal with ocular rosacea effectively. Most communities have such specialists. So, one can check with their general ophthalmologist or general physician to be referred to a cornea specialist. Most cornea specialists understand rosacea extremely well. The problem with going to a dermatologist is that most dermatologists are neither well schooled in looking at the ocular problems, nor do they really deal with the delivery of ocular medications. While they can treat the disease systemically, which is of course important, they don't really have a great handle on managing the eye disease. So, my advice would be that it is best to find an ophthalmologist who is qualified to take care of the eye.

Q: Are there any online or offline resources our members could read to help educate themselves, please?

A: Off hand, there is very little either on-line or off-line that deals specifically with ocular rosacea. I think the American Academy of Ophthalmology has some material. Of course, there are several text books that deal with the subject, but there is not very much on-line about ocular rosacea.

Q: Do you think ocular rosacea symptoms might be exacerbated by Demodex or other mites in the eyelash follicles or brows?

A: To be honest, there's no really definitive evidence that Demodex is a cause of ocular rosacea. So, Demodex-specific therapy is not really effective.

Q: Are there any new or existing proven treatments that you can recommend for patients to show their doctors? (eg What about topical metronidazole? What do you feel most optimistic about for the future, and could you give us any idea of what current studies might achieve, with an idea of likely time scales?)

A: People have been working on topical metronidazole for several years but there is not yet a drop in drop form that's available for the eye itself. No, there isn't really anything dramatically new that patients can go to their doctors about.

Q: What basic routine do you recommend, eg scrubs, drops, nutritional therapy, laser treatments, antibiotics?

A: Combine systemic antibiotic therapy, usually doxycycline with good lid hygiene. If there is prominent facial erythema, we usually go to topical metronidazole gel or cream. But for the most part, we treat patients with systemic medication, lid hygiene, and good ocular lubrication.

It would be greatly appreciated if you could offer any advice for the following particularly difficult cases, thank you.

Q: Patient 1: Has ocular rosacea, full-blown blepharitis, including swelling and distorted area around eyes and eyelids, gritty feeling and tearing in the eyes. Cannot take doxycycline antibiotics because they're contraindicated for the drugs prescribed for a serious case of Lyme disease. Could you recommend any treatment she might suggest to her eye specialist, and do you know if Lyme disease has any impact on ocular rosacea?

A: There is not ... aside from the fact that both are generalized inflammatory diseases, there is no interaction between Lyme infection and ocular rosacea that we are aware of. Are they able to take any antibiotics? Do we know what has been tried? To answer questions intelligently that are very patient specific, I would need to know more details about the patient. It's difficult for me to speak about specific patients.

Q: Patient 2: Aged 16, has had what was thought to be recurrent bouts of pink-eye for past 10 years, with eyes blood-red, burning, gritty, very sensitive to light. Has been teased for this over the years and is desperate for help. Has been to at least a dozen doctors: ophthalmologists, allergists (2 sets of full allergy tests came back blank) and a dermatologist. Could it possibly be ocular rosacea? Family lives in Memphis, TN, but would travel if it was possible to find anyone who could diagnose their daughter.

A: Could it be ocular rosacea? Certainly. It's just hard for me ... I cannot give you a clear answer without having seen the patient. Based on what you have told me, it certainly could be ocular rosacea and probably should be seen by an ophthalmologist who understands it.