ocular rosacea by sandra cremers, md
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TRANSCRIPT
A Hidden Concern in Ocular Rosacea
Sandra Lora Cremers, MD, FACS
March 2013
THUMP!
Rosacea, Boring and Not Glamorous?
1. Describe Epidemiology, Diagnosis, Pathophysiology, and Treatment of Rosacea and Ocular Rosacea
2. Discuss Recent Research Finding of Rosacea and Ocular Rosacea
3. Discuss Ocular Rosacea's Relationship to other Angiogenesis Based Diseases
Objectives:
1. Case Presentations
2. Diagnosis and Details
3. Observations & Collaborations
4. A Hidden Concern
Outline:
1. Case Presentations
79 yo white male presents complaining of "poor vision in right eye after cataract
surgery. Worse than before the surgery"
Case Presentation:
BCVA: 20/50 OD, 20/30 OSExternal exam:
Case Presentation:
R
Unhappy patient because he perceived a missed diagnosis of
ocular rosacea as the reason for less than expected vision after cataract
surgery.
Ultimate Diagnosis:
A Brief Historical Perspective
Young Rembrandt Older Rembrandt
2. Diagnosis and Details
Rosacea is a multifactorial, hyper-reactivity, vascular and neural based disease with a broad range of facial and manifestations where normal vasodilation is greater and more persistent and involves an autoimmune component where microscopic amounts of extravasated plasma induce localized dermal inflammation where repeated external triggers lead vasodilation, telangiectasias, redness with eventual fibrosis and hypertrophic scarring of the dermis.
A Definition of Rosacea
Subtypes of ROSACEA
What is Ocular Rosacea and How do you make the
Diagnosis?
1. In 3-58% of patients with Rosacea2. M=F3. European descent more common4. Starts in 20's and often worsens with age 5. Can be seen in kids
Epidemiology of Ocular Rosacea:
1. Burning2. Foreign body sensation3. Dry eye4. Tearing (reflex)5. Eye redness6. Mattering of eyelids
Symptoms:
1. Blepharitis & MGD2. Lid margin telangiectasia3. Conjunctivitis4. Recurrent chalazia5. Corneal pannus6. SPK7. Episcleritis, Scleritis (not common)8. Interstitial keratitis & residual corneal scarring
Signs:
1. Blepharitis & MGD2. Lid margin telangiectasia3. Conjunctivitis4. Recurrent chalazia5. Corneal pannus6. SPK7. Episcleritis, Scleritis (not common)8. Interstitial keratitis & residual corneal scarring
Signs:
Pathophysiology
Many Theories of Ocular Rosacea
Chemicals
Ingested Agents Climatic Exposures
Microbial
Bacillus oleronius
Demodex
Vascular
Pilosebaceous
anomalies
Matrix Degeneration
● Demodex folliculorum mites: Bacillus oleronius bacteria within
● Increased sulfated O-glycans in tear film
Many Theories of Ocular Rosacea
DEMODEX
1. Chronic Dry Eye
2. Corneal Vascularization
3. 2nd Bacterial Infections
4. Perforation
5. Increased graft failure after PK
Complications of Ocular Rosacea
Increased Graft Rejection in PK patients
Complications of Ocular Rosacea
Treatments
1. Lid hygiene: Warm Compresses Baby shampoo scrubs
2. Artificial tears, nonpreserved
3. Antibiotics po: doxycycline, tetracycline, clarithromycin,
metronidazole; Erythromycin for kids
4. Erythromycin ointment
5. Topical steroids
6. Restasis: Topical cyclosporine A b.i.d. x 3 mo
Usual Treatments of Ocular Rosacea
1. Intense Pulse Light Therapy (IPL)
3. LipiFlow
4. Intraductal MG Probing, Maskin
Newer Ocular Rosacea Treatments:
Doxycycline Risks:
Prevention
● Avoid foods, drinks, and situations that trigger outbreaks like sun
● Hat, sunglasses● increase Omega 3s intake
Usual Prevention:
Subtypes of ROSACEA
4. A Hidden Concern
1. If also had diabetes, tended to develop proliferative diabetic retinopathy
2. If they also had age related macular degeneration (ARMD), tended to develop wet ARMD
3. If they had a corneal transplant, they would tend to have a rejection more often.
Years of Observations of Ocular Rosacea
A Chance Encounter at Grand Rounds
Who is this man?
Nature. 2009 Jun 25;459(7250):1126-30. doi: 10.1038/nature08062.
Sandra Lora Cremers, MD, FACS Harvard Medical SchoolGrant: National Rosacea Society
Results: Patient 3, CD 31+
Results: Patient 1, CD31+
Results: Patient 1, VEGF+
1. Anti-Angiogenic at low doses
2. Anti-bacterial at higher doses
Doxycycline Magical Properties:
Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS
Grants: Harvard's 50th Anniversary Scholars Grant; National Rosacea Society; Lion's Eye
Neuronal-Driven Angiogenesis NGF
PDGF
Central Theory of Rosacea by Sandra Lora Cremers, MD, FACS
Grant provided by National Rosacea Society
Neuronal-Driven Angiogenesis NGF
PDGF
Doxy
-
nitric oxide (NO) synthetase
mitochondrial genes, ER stress cascade, growth factors, interleukins, cell cycle regulators, integrins, and components of the extracellular matrix; TNF-alpha, IL-10 and IFNgamma
low dose 0.5mg/kg/d significantly reduces BV growth & migration
Low Oxygen state
Rosacea is a multifactorial, hyper-reactivity, vascular and neural based disease with a broad range of facial and ocular manifestations where normal vasodilation is greater and more persistent and involves an autoimmune component where microscopic amounts of extravasated plasma induce localized dermal and meibomian gland inflammation and where repeated external triggers lead to angiogenesis (the recruitment of new blood vessels), vasodilation, teleangiectasias, redness with eventual fibrosis and hypertrophic scarring of the dermis and meibomian glands.
Likely a central underlying factor in all subtypes of rosacea, particularly ocular rosacea, involves VEGF and similar angiogenic factors.
More Complete Definition of Rosacea
1. Is Severe Ocular Rosacea due to increased
angiogenesis activity at the lid margin?
2. Would they benefit from topical anti-
angiogenic medications?
Future Research For Ocular Rosacea
1. Do severe ocular rosacea patients have an
increased risk of systemic angiogenesis?
2. Do these patients need to be evaluated for
an increased risk of internal tumors or
metastasis if primary tumors present?
Future Research For Ocular Rosacea
1. Avoid inflammatory factors (triggers, sun, smoke)
2. Eat antioxidants, Omega 3s,
2. If must treat with doxycycline, use lowest dose Start with 20mg q day; 40-mg, controlled release formulation
of doxycycline monohydrate is an anti-inflammatory drug
3. General medical check ups
Recommendations for Ocular Rosacea Patients:
Thank you for your attention.
1. Rohrich RJ, Griffin JR, Adams WP., Jr Rhinophyma: Review and update. Plast Reconstr Surg.2002;110(3):860–869. quiz, 870. 2. Scheinfeld NS. Rosacea. Skinmed. 2006;5:191–194.
3. Glycomic analysis of tear and saliva in ocular rosacea patients: the search for a biomarker. Ocul Surf. 2012 Jul;10(3):184-92 , Vieira AC, An HJ, Ozcan S, Kim JH, Lebrilla CB, Mannis MJ.2. http://rosacea-support.org/ocular-rosacea-diagnostic-test-one-step-closer.html3. 4. Perry HD, Doshi-Carnevale S, Donnenfeld ED, et al. Efficacy of commercially available topical cyclosporine A 0.05%in the treatment of meibomian gland dysfunction. Cornea. 2006;25:171-1753. Stone, Curr Opin Ophthalmol, 2004http://www.rosacea-treatment.org/6. http://videos.med.wisc.edu/videos/375717. Doxycycline's Effect on Ocular Angiogenesis: an In Vivo Analysis. Ophthalmology 2010 Sept, 117(9): 1782-1791. Cox, C, et al. 8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315879/9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-controlled, parallelgroup trial results evaluating the effects of 40 mgdoxycycline monohydrate controlled-releasecapsules in the treatment of rosacea. Posterpresented at: 64 th American Academy ofDermatology Meeting ; March 3–7, 2006; San Francisco, Calif.
References:
9. Del Rosso JQ, Bikowski JB. Multicenter, doubleblind, randomized, placebo-controlled, parallelgroup trial results evaluating the effects of 40 mgdoxycycline monohydrate controlled-release capsules in the treatment of rosacea. Poster presented at: 64 th American Academy of Dermatology Meeting ; March 3–7, 2006; San Francisco, Calif.10.http://www.globalacademycme.com/fileadmin/pdf/supplement_pdf/fczjw6vm_sanews_supplement46.pdf
References continued:
