Welcome back to Dry Eye Fireside Chat. In this episode, Damon Dierker, OD, FAAO, sits down with Janelle L. Davison, OD, to discuss the challenges of identifying ocular rosacea, specifically in patients of color. They also offer insights to best manage this complex condition.
What is ocular rosacea?
Dr. Davison defines ocular rosacea as chronic inflammation of the periorbital tissue, specifically around the upper and lower lids, with telangiectasia. Just as these small red blood vessels are tell-tale signs of facial rosacea on the cheeks, nose, and chin, they also indicate rosacea of the ocular variety when present on the lid margin.
As ocular rosacea is often the cause of unresolved dry eye symptoms, it is important to learn to identify and diagnose the disease. Dr. Dierker notes that many patients have never heard of ocular rosacea. Even individuals who have been diagnosed by a dermatologist with facial rosacea are unaware that it can negatively impact their ocular surface, so education is a key component.
Recognizing rosacea in patients of color
As founder and CEO of the Visionary Dry Eye Institute—Atlanta’s only treatment center solely dedicated to dry eye and other chronic ocular surface diseases—Dr. Davison sees a host of different patients, many of whom are people of color, specifically of African, South Asian, or Hispanic descent. In this patient population, both ocular and facial rosacea are both misdiagnosed and underdiagnosed as they are more difficult to see with the naked eye.1
However, unlike previously thought, rosacea is not more common in lighter-skinned populations.1 One study found that ocular rosacea presentation between fair-skinned and dark-skinned females was comparable, with meibomian gland dysfunction and eyelid telangiectasia being an early predictor in both.2 In her research, Dr. Davison has discovered that approximately 10% of patients of color have ocular rosacea; however, she believes that number is much higher.
Therefore, when patients of color reveal they have had long-standing symptoms of severe dry eye disease—such as pain, itching, watering, and redness (especially around the lid margin)—that have not improved with standard treatments, she orders a comprehensive diagnostic exam to determine if ocular rosacea is the underlying cause.
Diving deeper to diagnose ocular rosacea
As with any diagnosis, a comprehensive history is key. However, considering that 58 to 72% of patients who have facial rosacea are going to also exhibit some level of ocular rosacea,3 perhaps the most important question is, “Have you ever been diagnosed with rosacea?”
After attaining this answer, Dr. Davison then moves on to the standard line of questioning outlined in the dry eye questionnaires (e.g., Ocular Surface Disease Index [OSDI], Standard Patient Evaluation of Eye Dryness [SPEED], Dry Eye Questionnaire [DEQ]). After taking a thorough history and performing a physical evaluation, Dr. Davison utilizes her full armamentarium of tools to get a complete picture and accurate diagnosis.
For patients suspected of having ocular rosacea, Dr. Davison's comprehensive ocular surface examination includes:
- A slit lamp exam with particular attention to telangiectasia on the lid margins as well as Demodex
- Meibography to determine the degree of meibomian gland dysfunction
- MMP-9 to detect elevated levels of the inflammatory marker matrix metalloproteinase-9
- Tear osmolarity to assess the biophysical measurement of the tear film
- Anterior segment imaging, such as anterior segment slit photography
- Lactoferrin testing to determine whether the dry eye is of the aqueous deficient or evaporative type
The information gathered then allows her to determine how advanced the condition has become so she can formulate an individualized treatment regimen.
Managing ocular rosacea with light-based therapy
For Dr. Davison, intense pulsed light (IPL) therapy is the go-to treatment for ocular rosacea. She explained, “I have been blessed to do a lot of research and find a light-based therapy that I can use off-label.” She has several units in her facility, but has found one specific machine offers the best results on patients with darker skin tones.
She attributes this to the fact that the particular unit provides the ability for her to navigate the wavelengths as well as the pulse in between those wavelengths, ensuring she can safely perform these procedures on patients with more melanin. However, she noted that there still has not been extensive research on the use of IPL for patients of color.
Many of the patients Dr. Davison encounters present with moderate or moderate-severe symptoms and have gone unmanaged for an extensive amount of time. IPL requires ongoing treatment for 3 to 6 weeks to see a significant decline in symptoms, and these individuals are eager for quick symptom relief. Therefore, they are best served with topical treatments to ease discomfort in conjunction with in-office IPL and thermal pulsation to address any meibomian gland dysfunction.
In closing
Both Drs. Dierker and Davison agree that once you have opened your eyes to the prevalence of ocular rosacea, you will begin to identify more and more patients with this condition who would benefit from treatment.
Many of these patients have gone undiagnosed and untreated for significant periods of time. By offering them the right diagnosis and tailored treatment, you can greatly improve their ocular health and quality of life.
