“Matthew,” a 60-year-old patient of mine, has a true heart of gold. He moved to my area five years ago and works as a pastor in crisis situations, devoted to providing any comfort he can in times of human suffering.

Unfortunately, his own comfort was limited by severe facial and ocular rosacea. His symptoms remained uncontrolled, despite significant dietary efforts. He had only a high-deductible catastrophic health plan, and virtually all prescription medications were unaffordable to him.

Upon examination, it was clear that the patient suffered from advanced papulopustular and ocular rosacea. He told me that he had experienced these symptoms for 20 years, with gradually increasing severity. He reported that, for the past five years, his eyes were routinely burning, stinging and watering. His exam showed significant dry eye disease (DED) signs, including 3+ injection, 3+ SPK and tear breakup time (TBUT) of only 4 seconds OU.

An advanced case like this requires a multifaceted approach. Unfortunately, pharmacological options were closed to us because of high out-of-pocket expenses due to his poor insurance coverage. He was limited to lubricant drops, omega-3 supplements, topical generic metronidazole cream and following a gluten-free diet. Clearly, these measures were not sufficient to control his facial and ocular rosacea, nor to prevent progression. I felt frustrated at the situation yet compelled to help him get access to treatment.

I recommended an efficient, broad-based method to address his facial and ocular rosacea: a series of intense pulsed light (IPL) therapy sessions.

CONSIDERING ROSACEA

Last year, the ROSacea COnsensus (ROSCO) panel published a new definition of rosacea and its diagnosis and treatment.¹ The panel found that ocular manifestations of the disease may be present with or without facial symptoms. I have noted that ocular symptoms often occur early in patients with facial rosacea, giving us an opportunity to treat patients early in the disease state and potentially improve long-term outcomes in preventing progression, facial sequelae and ocular sequelae. Rosacea-induced dilation of the superficial vasculature, development of telangiectasia, upregulation of proinflammatory mediators and eyelid edema can all compromise and complicate meibomian gland health, as well as set the stage for development and worsening of DED and meibomian gland dysfunction (MGD) in “vicious circle”^2,3 fashion.

IPL THERAPY FOR ROSACEA

Given the close relationship between facial rosacea and ocular rosacea, and the abundant peer-reviewed literature demonstrating the benefits of IPL for facial and ocular rosacea, my practice offers IPL to improve ocular surface conditions such as MGD-related DED. IPL is a drug-free, drop-free, safe and easy-to-perform technology for addressing skin rosacea.⁴ Recent papers demonstrate that IPL treatments significantly reduce DED signs and symptoms,^5,6 including decreased corneal staining, normalized tear film osmolarity, improved TBUT, improved meibomian gland secretion scores and decreased inflammatory markers in the tear film.^5,6 The mechanism of actions are well known to our dermatology colleagues and include immunomodulation of the inflammatory burden, destruction of Demodex, decrease of the bacterial load, photomodulation of mitochondrial activity and rejuvenation of collagen production.

Recently, the second international dry eye workshop (TFOS DEWS II) report recommended IPL as a level 2 treatment for chronic dry eye disease (CDED) patients, along with physical heating and expression of the meibomian glands, topical corticosteroids and immunomodulatory drugs.⁷ Among the various therapeutic alternatives offered for treatment of CDED, IPL is unique in that in addition to treating telangiectasias, inflammation and Demodex, it also has an aesthetic benefit. IPL improves skin color and texture while also stimulating collagen production, which improves fine lines. Patients treated with IPL report better feeling and better looking eyes, as well as improved color, texture and tone of their skin.

MY PATIENT’S IPL RESULTS

Treating concomitant and contributory DED conditions such as rosacea with a multidisciplinary approach is an effective strategy. Addressing rosacea as a local-regional disease process is in line with this rationale.

For a patient like Matthew, who had a combination of severe facial and ocular rosacea and could not afford a pharmacological approach, I felt that a series of IPL treatments would be a particularly effective approach. Clinically, IPL has performed well for improving MGD-related DED signs and symptoms in patients with various severity levels and access to additional therapeutics.

My patient received a standard schedule of IPL therapy: four treatments scheduled three to five weeks apart. Such treatment is typically followed by maintenance treatments once or twice a year, depending on disease severity.

After four IPL treatments, signs and symptoms of DED, including the appearance of his eyes, all significantly improved. Tear film osmolarity was restored to within the physiological range, the MMP-9 levels in tear samples were nearly negative, TBUT in both eyes increased from four to seven seconds and corneal staining almost disappeared. His facial rosacea symptoms and ocular symptoms, as evaluated by the SPEED questionnaire, went from a score of 18 to 6 over the course of treatment.

After treatment, the patient attended a four-day retreat on the blustery Oregon coast then happily reported that he only once needed preservative-free lubricating drops. This was a striking contrast to his use of lubricating drops several times per day before the IPL treatment sessions started.

CONCLUSION

The patient and I are highly satisfied with these excellent improvements. People now see his kind, blue eyes, instead of red ones. Not only does he look and feel better, he also finds that people respond even more favorably to him in his work as a pastor. He still uses omega-3 supplements and sticks to his gluten-free diet, but now he does so with an improved facial appearance and comfortable, quiet eyes. IPL was clearly the best choice for Matthew’s severe rosacea, and greatly improved his quality of life. OM

REFERENCES

1. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176:431-438.
2. Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 2016;100:300-306.
3. Geerling G, Baudouin C, Aragona P, et al. Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting. Ocul Surf. 2017;15:179-192.
4. Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. 2005;31:1285-1289.
5. Dell SJ, Gaster RN, Barbarino SC, Cunningham DN. Prospective evaluation of intense pulsed light and meibomian gland expression efficacy on relieving signs and symptoms of dry eye disease due to meibomian gland dysfunction. Clin Ophthalmol. 2017;11:817-827.
6. Liu R, Rong B, Tu P, et al. Analysis of cytokine levels in tears and clinical correlations after intense pulsed light treating meibomian gland dysfunction. Am J Ophthalmol. 2017;183:81-90.
7. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017.15:575-628.

About the Author

Laura M. Periman, MD, is an ocular surface disease expert located in Seattle, Wash.

Disclosures: Dr. Periman is a speaker for Allergan, BioTissue, Lumenis and Topcon and is a consultant for Allergan, Eyedetec, Science Based Health, Shire, Sun, TearLab and Visant.