Managing Dry Eye From Rosacea in a Soft Lens Wearer
BY LEO SEMES, OD, FAAO
A 50-something female who was a long-time soft contact lens wearer complained of mild irritative symptoms and decreased wearing time. Tear supplements (Refresh Contacts [Allergan]) initially proved sufficient to minimize her symptoms. But over the years, her problem became much more clinically significant. She was diagnosed with rosacea, and she developed a papillary response on both lower (but not upper) lids.
Early Treatment Attempts
Treatment trials over the course of two years included Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), various tear supplements, oral antibiotics (mainly doxycycline 100mg daily) and topical antihistamines and mast cell stabilizers. She was either noncompliant or unwilling (by admission) to be consistent with many of these treatment strategies even though it meant uncomfortable contact lens wear.
Most recently, I tried a two-week course of Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb) instilled before contact lens application and following removal each day.
Reducing Inflammation is Key
Recognizing the inflammatory component of dry eye, and to reduce the impact of the allergic response, I suggested a course of Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) twice per day for two weeks. After the initial trial while she discontinued contact lens wear, her symptoms and clinical signs improved. We observed reduction of the papillary response and re-establishment of the epithelial integrity of the ocular surface.
While some may question the wisdom of using a steroid on a compromised ocular surface, her presentation was minimal and she had discontinued contact lens wear. In addition, intraocular pressure was in the normal range and her follow up was two weeks from the initial visit.
At the first follow-up visit, I increased the Lotemax to four times per day and had her resume contact lens wear. She did not instill the drops while the lenses were in her eyes. We also agreed to a regimen of warm compresses (dry heat with a rice sock) twice per day to mobilize lipid secretion as well as 1,000mg of fish oil orally per day.
There are several factors at work here. Her allergies (environmental and seasonal) contribute adversely to her lens wearing comfort. Attacking these and the inflammatory components of the ocular surface problems helped to minimize that aspect of her discomfort. The rosacea contributes to the meibomian gland dysfunction, so reducing inflammation, which was unsuccessful with Restasis perhaps because of noncompliance, was a primary objective. Supplementary treatment strategies include warm compresses and oral fish oil supplementation.
In addition, I recommended that she use Optive (Allergan) lubricant eye drops when she was not wearing her contact lenses and to use Refresh Contacts for relief during contact lens wear.
While these strategies may seem complex and may adversely affect compliance, I carefully explained to the patient that some (topical steroid and warm compresses) were temporary or situational. Others (fish oil, lubricant drops) would be required more consistently. In addition, when seasonal allergies exacerbate symptoms, we can resume the Lotemax.
In the event of epithelial compromise, an antibiotic/steroid combination may be an alternative for the future. Other anti-inflammatory strategies include fish oil supplementation for meibomian gland dysfunction secondary to rosacea. CLS
Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.