How to treat ocular rosacea?

Ocular rosacea is not invariably associated with skin forms of rosacea. It can be found in both adults and children. However, in the absence of skin symptoms, the diagnosis of the ocular form is often delayed, particularly in children, who less frequently show skin involvement.

In terms of diagnosis, the identification of ocular rosacea largely relies on clinical signs. It is characterised by several symptoms, including redness, tearing, chalazions, telangiectasias, blepharitis, and sometimes vision disturbances.

Initially, when the condition first presents, the doctor prescribes daily eyelid hygiene care. If this is not sufficient or if the ocular condition is too severe, topical or oral antibiotics are prescribed in conjunction. It should be noted that precautions must be taken for pregnant or breastfeeding women, and children.

Indeed, cyclines are contraindicated in these populations due to the risk of complications they present. They can notably cause altered bone growth and permanent discolouration of teeth in children, and have a potential teratogenic effect.

Beyond the available medicinal treatments, maintaining and adopting a strict ocular hygiene contributes to the optimisation of care management. Artificial tears are generally prescribed for daily use to counteract dry eyes. The use of warm compresses soaked in water or saline solution, applied to the eyes for about ten minutes a day, is highly recommended.

Furthermore, ocular rosacea, which originates from the obstruction of the Meibomian glands, can be alleviated through the practice of a daily draining massage. The aim of this massage is to drain the glands, whose natural flow is hindered by the inflammation associated with rosacea. The massage will thus limit the effects of the inflammation and aid in naturally hydrating the ocular area.

Topical antibiotics may also be recommended and allow for effective management of the ocular form of rosacea. For instance, tetracycline, an antibiotic from the cycline family, can be prescribed in the form of eye drops. Furthermore, fluoroquinolone in eye drops, fusidic acid and the metronidazole in gel form can also be prescribed.

Furthermore, topical cyclosporine can also be utilised. This is a cyclic polypeptide immunomodulator with immunosuppressive and anti-inflammatory properties. It is passively absorbed by T lymphocyte infiltrates in the cornea and conjunctiva, leading to the inactivation of calcineurin phosphatase. This inactivation results in the inhibition of pro-inflammatory cytokine production, such as IL-2 and T-cell growth factor (TCGF), and stimulates the release of anti-inflammatory cytokines.

In recent years, new active ingredients have demonstrated their effectiveness in the treatment of ocular rosacea. They are now part of the prescribed treatments to manage the disease. In a study by BONINI in 2013, the topical application of azithromycin was explored as a new treatment for rosacea. This study utilised the Oxford score to quantify the damage present on the epithelial surface in patients suffering from dry eye.

Furthermore, the TBUT (Tear Film Break-up Time) or the time it takes for the tear film to break up was measured, along with the condition of the Meibomian glands and the reduction of rosacea symptoms. After a month of daily treatment, a significant improvement was observed in patients. Therefore, topical application of azithromycin could potentially be used to treat ocular rosacea over a relatively short period, either alone or in addition to another treatment, under the advice and prescription of a healthcare professional.

Antibiotics from the cycline class, such as doxycycline, can be prescribed. This is available in the form of tablets or capsules and is the standard treatment for ocular rosacea. Indeed, thanks to its anti-inflammatory properties, it is effective against most symptoms of this disease, particularly in terms of blepharitis and dry eyes.

However, it is essential to remain vigilant about the potential side effects it may cause and adhere to the doctor's prescription. Moreover, this medication causes photosensitivity, so it is recommended to avoid sun exposure during the treatment.

Several studies have been conducted on the impact of laser treatments in the context of ocular rosacea. They have shown promising effects in managing the symptoms. The use of Intense Pulsed Light (IPL) laser allows it to be absorbed by the telangiectasias, thus leading to their coagulation.

Furthermore, the Nd-YAG laser (Neodymium-doped Yttrium Aluminium Garnet) has also shown good results on ocular rosacea. It emits light at a specific wavelength of 1,064 nm, which is then successively absorbed by melanin pigments, located in the sub-retinal tissue, and by haemoglobin in the blood vessels. This light is then transformed into heat, allowing the ocular tissues to coagulate.

Laser therapies generally have good effects on the symptoms of ocular rosacea, primarily on the dilation of ocular blood vessels and the resulting redness.

To alleviate the symptoms of bothersome ocular rosacea, there are several types of procedures available to restore the passage between the tear sac and the nasal cavities. The tear duct occlusion, which involves preventing tear drainage to retain tears on the ocular surface, can be used in cases of refractory dry eye to reduce this symptom.

Furthermore, following the inflammation of the Meibomian glands, some patients develop a chalazion , which is a small benign eyelid cyst that can develop on the lower or upper eyelid of the eye. A drainage can then provide significant relief and improved comfort for patients.

Furthermore, considering the risks of recurrent ulceration, patients may require the application of tissue adhesives. Conservation-oriented interventions can sometimes fail to alleviate the occlusion of healed Meibomian glands. In this case, the intracanalicular probing of the Meibomian gland is used to manually open the healed orifices, thus allowing the flow of their contents and stabilising the tear film.

• ABDULLAH A. & et al. The impact of pulsed dye laser on the dermatology life quality index in patients with erythematotelangiectatic rosacea: an evaluation. Journal of Clinical and Aesthetic Dermatology (2013).

• BONINI S. & al. Topical azithromycin as a novel treatment for ocular rosacea. Ocular Immunology and Inflammation (2013).

• ZIERHUT M. & al. Treatment of ocular rosacea with once-daily low-dose doxycycline. Journal of Cornea and External Disease (2014).

• TAKMAZ T. & al. Treatment of ocular rosacea: comparative study of topical cyclosporine and oral doxycycline. International Journal of Ophthalmology (2015).

• ADAM A. & al. Treatment of ocular rosacea. Review of Ophthalmology (2018).