The Patient's Guide to Dry Eye Syndrome: Ocular Rosacea

Red, itchy, watery, inflamed eyes with clogged meibomian glands.  Sound familiar?  Ocular rosacea is very similar to Meibomian Gland Dysfunction/Posterior Blepharitis from my most recent dry eye post, and in fact some would consider it a subset of the same disease.  To draw on a personal example, I recently had a patient that had been treated by several different OD's for dryness.  He told me that a doctor had been treating his eyelid gland disease without success, and then he went to a specialist who took one look at his eyes and said he had ocular rosacea.  He wondered why no one had told him that before?  I'm not sure how convincing it was when I told him his ocular rosacea and eyelid gland issues were one and the same thing, just different variations of the same ocular syndrome.  There isn't a set definition for when we call these symptoms ocular rosacea versus when we just call them MGD or bleph, but here are some guidelines:

• Red, dilated blood vessels along the eyelid/lash line.  These are called telangiectasia and are very pronounced in rosacea
• Other rosacea of the face, especially cheeks and the end of the nose.  Sometimes the rosacea is so pronounced at the nose it can take on a bulbous appearance, called rhinophyma
• Symptoms are worsened with exposure to: 
• heat
• spicy foods
• coffee or alcohol

TELANGIECTASIAS are thin, faint blood vessels just interior to and at the lash line that cause an appearance of redness to the observer and cause marked inflammation also affecting the eyelid meibomian glands.

TREATMENT:  We treat ocular rosacea in much the same way that we treat Meibomian Gland dysfunction, with lid scrubs and massage.  Heat is an exacerbating factor to rosacea, however, so I typically don't prescribe the hot compresses in this case.  

Another excellent treatment is Doxycycline (typically over the course of 1 month).  Doxy is used not as an antibiotic, but for its anti-inflammatory properties.  Remember, Doxy can cause severe sunburns or rashes, and is not safe in children under 8 or pregnant women.  In these cases a topical drop like Azasite or Besivance instilled in the eye and rubbed along the lashline may be preferable.  

For acute inflammation, sometimes we need to use a steroid ointment like FML or the new Lotemax ointment along the lids to improve comfort.  This is also true for blepharitis.  

OMEGA 3 FATTY ACIDS: great for improving dry eye symptoms associated with inflammation and meibomian gland issues.  Typically 1000 mg is the recommend dosage.

As far as nutritional supplements, Vitamin D is a well-known anti-inflammatory agent that may also be of benefit.  Omega 3 fatty acids (DHA)/Fish oil supplements can also be very helpful with improving oil gland secretion and decreasing inflammation. I also like to refer the patient to a dermatologist if they have other facial areas affected by rosacea.  Counselling the patient to avoid the above exacerbating factors is also helpful.

SUMMARY:

How do you know if you have ocular rosacea or just regular old meibomian gland dysfunction?  I guess the important take home message is that it might not matter.  Treatment is generally the same except for the exacerbating factors (like heat!) that need to avoided in rosacea.  One thing to remember is that if you have been diagnosed with rosacea, you will definitely be more at risk for dry eye, so make sure you tell your eye care provider about this diagnosis and any medications or gels you may be using!