Eyeworld

APRIL 2022 | EYEWORLD | 85 C Reference 1. Gallo RL, et al. Standard classi- fication and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78:148–155. epithelial keratopathy, chalazion formation, cor- neal neovascularization, subepithelial infiltrates, and spade-like peripheral infiltrates. Some of the dermatological aspects of rosa- cea, such as facial flushing, are reversible. Other changes, such as severe rhinophymatous nasal changes, may be long lasting, he said. Oculocutaneous rosacea can lead to inflam- mation with associated ulceration and scarring, Dr. Cheung said. Superficial changes can often be improved or reversed. "In the later stages, it can be difficult to reverse stromal thinning, scarring, or the associated neovascularization that develops," he said. Dr. Perry said that ocular rosacea needs to be treated months before cataract surgery. He added that Demodex folliculorum is frequently associated with rosacea, noting the importance of treating the Demodex infestation before sur- gery as well. "You have to look at the eyelashes and see if there is cylindrical dandruff," he said. The cylindrical dandruff indicates in 80–90% of patients the presence of Demodex mites. Patients may also have ocular inflammation. "You have to think of treating not only the rosacea be- cause that will reflect the presence of increased amounts of bacteria, but you have to also eradi- cate the Demodex," Dr. Perry said. Demodex carry Staph bacteria on their surface and Bacillus oleronius and cereus in their gut. Treatment strategies Patients with oculocutaneous rosacea benefit from avoiding triggers, such as certain foods, beverages, medications, and environments that exacerbate flushing, Dr. Cheung said. Addi- tionally, certain systemic antibiotics (e.g., oral doxycycline/tetracycline, azithromycin) can treat both ocular and cutaneous rosacea. Other treatment strategies are based on the type of ocular pathology, he said. Meibomian gland dysfunction and bleph- aritis treatment often begins with conservative treatments. "This can include warm compresses, eyelid scrubs, and digital massage," Dr. Cheung said. "Other therapies include oral omega-3 fatty acid supplementation, topical antibiotics, mi- croblepharoexfoliation, heat application with/ without eyelid mechanical stimulation, meibo- mian gland probing, and intense pulsed light." Related dry eye can benefit from frequent preservative-free artificial tears/ointments, punctal occlusion, anti-inflammatory agents (cyclosporine, lifitegrast, low-dose topical cor- ticosteroids), and autologous serum tears, Dr. Cheung said. Treatment of conjunctivitis and keratitis may benefit from topical corticoste- roids and anti-inflammatory agents. If there is any infiltrate or ulceration, cultures and topical anti-microbial treatment is advised prior to corticosteroids, he said. "For severe ocular surface disease, scarring and thinning may cause irregular astigmatism and benefit from a hard contact lens for visual rehabilitation," Dr. Cheung said. "Although rare, stromal thinning and perforations may need a bandage contact lens, cyanoacrylate gluing, amniotic membrane, tarsorrhaphy, conjunctival flap, and/or lamellar keratoplasty." Dr. Cheung noted that he does not have much experience with meibomian gland prob- ing and intense pulsed light, but he has found the other treatment options effective with a patient-specific regimen. Dr. Perry noted that there are several good treatments for rosacea. However, he said that one problem is that a lot of clinicians don't realize that sometimes steroids may make acne rosacea worse. For ocular rosacea, steroids and doxycycline systemically have good results, he said, but if the patient has another form of rosacea, which continued on page 86 Peripheral keratitis in rosacea Source (all): Vincent de Luise, MD

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