the eye in dermatologic disease - nsu college of optometry · the eye in dermatologic disease...

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The Eye inThe Eye in Dermatologic Disease Dermatologic Disease

Joseph J. Pizzimenti, OD, FAAOJoseph J. Pizzimenti, OD, FAAOAssociate ProfessorAssociate Professor

Nova Southeastern UniversityNova Southeastern [email protected]

Financial DisclosureFinancial Disclosure!! I have received honoraria from, participated inI have received honoraria from, participated in

advisory boards and speaker panels for:advisory boards and speaker panels for:!! AlconAlcon!! Carl Carl Zeiss MeditecZeiss Meditec!! ReichertReichert!! VSPVSP!! ZeavisionZeavision

!! I am I am Co-founder and Partner of Optometry BoardCo-founder and Partner of Optometry BoardCertified, LLC.Certified, LLC.

!! I have no proprietary interest in any product, andI have no proprietary interest in any product, andmy affiliations have no influence on the content ofmy affiliations have no influence on the content ofthis lecture.this lecture.

Course GoalsCourse Goals!! To provide clinicallyTo provide clinically

relevant informationrelevant informationon dermatologicon dermatologicdisease, emphasizingdisease, emphasizingthose frequently seenthose frequently seenin optometry.in optometry.!! UnderstandingUnderstanding

rosacearosacea!! Infectious Infectious DermDerm!! Neoplastic DermNeoplastic Derm

!! Case examplesCase examples

Skin isSkin is……!! A A barrierbarrier to protect the to protect the

body from thebody from theenvironmentenvironment

!! A A temperaturetemperature regulatorregulator!! An An immuneimmune organ to organ to

prevent and combatprevent and combatinfectionsinfections

!! A A sensorysensory organ to detect organ to detecttemperature, touch, pain,temperature, touch, pain,vibration, etc.vibration, etc.

!! Working to Working to renewrenew itself itselfevery secondevery second

Layers of SkinLayers of Skin Layers of SkinLayers of Skin

!! EpidermisEpidermis!! Outermost layerOutermost layer!! Consists of 2 main cell typesConsists of 2 main cell types

!!keratinocyteskeratinocytes and and melanocytesmelanocytes!! produced in the basal layerproduced in the basal layer

!! Protective outer layer called the Protective outer layer called the stratumstratumcorneumcorneum

!! Contains no blood vesselsContains no blood vessels

2

EpidermisEpidermis

E

Protects

Produces K-cytes and M-cytes

Layers of SkinLayers of Skin

!! DermisDermis!! Thicker layer of fibrous connectiveThicker layer of fibrous connective

tissuetissue!! Supports and binds the epidermis to theSupports and binds the epidermis to the

subcutaneous tissuesubcutaneous tissue!! Produces substances that lend structureProduces substances that lend structure

and support:and support:!!collagencollagen!!elastinelastin!! reticulinreticulin

DermisDermis

!! The dermis providesThe dermis providesnutrition to itself andnutrition to itself andthe epidermisthe epidermis

!! The dermis contains:The dermis contains:!! NervesNerves!! BloodBlood!! lymph vesselslymph vessels!! Sebaceous glandsSebaceous glands

Layers of SkinLayers of Skin!! HypodermisHypodermis

!! Subcutaneous layerSubcutaneous layer!! Comprised of loose connective tissueComprised of loose connective tissue!! Contains variable amounts of adiposeContains variable amounts of adipose

Glossary of Dermatology TermsGlossary of Dermatology Terms

!! CystCyst!! Liquid inside epithelial wallLiquid inside epithelial wall

!! PapulePapule!! Small, solid Small, solid eleveted eleveted skinskin

!! PustulePustule!! Elevated, pus-filled lesionElevated, pus-filled lesion

!! PlaquePlaque!! Palpable, plateau-likePalpable, plateau-like lesionlesion

Glossary of Dermatology TermsGlossary of Dermatology Terms

!! ScaleScale!! Flaking of keratinFlaking of keratin

!! UlcerUlcer!! Skin loss that involves dermisSkin loss that involves dermis

!! VesicleVesicle!! Blister-like elevation Blister-like elevation w/clear w/clear fluidfluid

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Case: 54-year-old White MaleCase: 54-year-old White Male!! 3-week 3-week history of irritation and redness at lid margins

OU. Medical history was positive for rosacea, diagnosed3 years earlier.

! He was using topical metronidazole gel for associatedskin lesions.

! VA was 20/20 OD and OS.! Biomicroscopy revealed mild blepharitis and significant

meibomian gland dysfunction (meibomitis) OU. Palpebralconjunctival hyperemia was also present OU.

! Grade 1 punctate epithelial keratopathy (PEK) waspresent on the inferior aspect of each cornea, withoutinfiltrate or neovascularization.

54-year-old White Male54-year-old White Male

Photo Courtesy of A. Kabat

What is your assessment?What is your assessment?

Plan?Plan?

Rosacea Rosacea ReviewReview

!! GoalsGoals!! Review symptoms, signs,Review symptoms, signs,

pathophysiologypathophysiology, and stages of , and stages of rosacearosacea..!! Discuss diagnosis and management.Discuss diagnosis and management.!! Discuss symptoms, signs,Discuss symptoms, signs,

pathophysiologypathophysiology, diagnosis, and management, diagnosis, and managementof of ocular ocular rosacearosacea..

!! Highlight new research in the areas ofHighlight new research in the areas ofrosacea rosacea triggers, classification, andtriggers, classification, andtreatments.treatments.

Introduction to RosaceaIntroduction to Rosacea

!! What is Rosacea?What is Rosacea?!! A chronic dermatologic condition that affectsA chronic dermatologic condition that affects

the convexities of the central aspect of thethe convexities of the central aspect of theface, including ocular tissues.face, including ocular tissues.

!! Characterized by symptoms of Characterized by symptoms of facial flushingfacial flushingand a spectrum of clinical signs, includingand a spectrum of clinical signs, includingerythema, telangiectasia, coarseness of skin,erythema, telangiectasia, coarseness of skin,and an inflammatory papulopustular eruptionand an inflammatory papulopustular eruptionresembling acne.resembling acne.

Facial flushing

Bumps (papules) and/orpimples (pustules)

Phyma=excess tissue

(rhinophyma)

Symptoms and SignsSymptoms and Signs

Rosacea.org

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BackgroundBackground

!! Rosacea is characterized byRosacea is characterized byexacerbations and remissions.exacerbations and remissions.

!! Treatment of rosacea Treatment of rosacea empiricallyempirically targets targetssigns and symptoms becausesigns and symptoms becauseinvestigators do not precisely understandinvestigators do not precisely understandits pathophysiology.its pathophysiology.

!! Long-term therapy is usually required inLong-term therapy is usually required inorder to control signs and symptoms.order to control signs and symptoms.

Who Gets Rosacea?Who Gets Rosacea?


!! Range of occurrenceRange of occurrence!! In U.S., In U.S., 1 in 20 adults1 in 20 adults exhibits dermatologic exhibits dermatologic

featuresfeatures!! Of these, up to 60% experience ocularOf these, up to 60% experience ocular

complications.complications.!! 14 million Americans14 million Americans!! More common in fair-skinned, under-reportedMore common in fair-skinned, under-reported

in races with increased skin pigmentation.in races with increased skin pigmentation.!! Peak incidence in 4Peak incidence in 4thth to 7 to 7thth decades. decades.


!! Females affected Females affected 2-3 X2-3 X as commonly as as commonly asmales.males.

!! Often more severe in men.Often more severe in men.!! Rule of Thumb:Rule of Thumb:

!! WomenWomen!! Cheeks more involvedCheeks more involved

!! MenMen!! Nose more involvedNose more involved

www.revoptom.com

Will your children get Will your children get rosacearosacea??!! Once thought to be rare,Once thought to be rare, rosacea rosacea in childhoodin childhood

and adolescence is being recognized moreand adolescence is being recognized morefrequently.frequently.

!! Doan reported 80 subject case series.Doan reported 80 subject case series.!! 3:1 F:M3:1 F:M!! Heredity a factor.Heredity a factor.!! Ocular Ocular rosacea rosacea in children may be in children may be particularyparticulary

aggressive.aggressive.!! Childhood Childhood hordeola hordeola associated associated w/adult rosaceaw/adult rosacea..

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What causes What causes rosacearosacea??

Dermatologic Urban MythDermatologic Urban Myth

DidnDidn’’t inhale?t inhale?

FictionFiction: : ““Rosacea is causedRosacea is causedby alcoholism and smoking.by alcoholism and smoking.””Fact: Smoking and alcoholare not causative, but maytrigger signs of rosacea.

Potential Causes of RosaceaPotential Causes of Rosacea

!! Precise pathophysiology is unknownPrecise pathophysiology is unknown!! 2 primary etiologic components:2 primary etiologic components:

!! VascularVascular!! InflammatoryInflammatory

!! Vascular ComponentVascular Component!! Early signs are Early signs are cutaneouscutaneous vascular dilatations vascular dilatations

!! SunlightSunlight is a is a major trigger*major trigger* for small vessel for small vesseldamagedamage

!! May explain low incidence in darker racesMay explain low incidence in darker races

Etiology of RosaceaEtiology of Rosacea!! Inflammatory ComponentInflammatory Component

!! Later stages include papules, pustules,Later stages include papules, pustules,rhinophyma rhinophyma (bulbous nose), ocular (bulbous nose), ocular rosacearosacea

!! Fundamental abnormality in the Fundamental abnormality in the sebaceoussebaceousglandsglands

!! Type-4 hypersensitivity, Type-4 hypersensitivity, Demodex mites, H.pylori have all been hypothesized asinflammatory causes.inflammatory causes.

InflammationInflammation

Proposedinflammatorymodel Vascular

“loop”

Recent Research FindingsRecent Research Findings

!! CathelicidinsCathelicidins are anti-microbial moleculesare anti-microbial moleculesproduced as part of immune system.produced as part of immune system.!! More abundant in More abundant in rosacea rosacea patients.patients.!! May cause inflammatory papules andMay cause inflammatory papules and

pustules as well flushing and pustules as well flushing and telangiectasiatelangiectasia..

!! Yamasaki K, Yamasaki K, DiNardo DiNardo A, A, Bardan Bardan A, et al. Increased serineA, et al. Increased serineprotease activity and protease activity and cathelicidins cathelicidins promotes skin inflammationpromotes skin inflammationin in rosacearosacea. Nature Medicine 2007;13:975-980.. Nature Medicine 2007;13:975-980.

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Recognizing Recognizing RosaceaRosacea: Stages: Stages!! PrerosaceaPrerosacea

!! FlushingFlushing!! Recurrent episodes of facial rednessRecurrent episodes of facial redness!! Commonly triggered by sunlight, alcohol, tobacco, spicy orCommonly triggered by sunlight, alcohol, tobacco, spicy or

hot food/beverages, stresshot food/beverages, stress!! ErythemaErythema

!! Persistent midfacial rednessPersistent midfacial redness!! Nose, chin, cheeks, central foreheadNose, chin, cheeks, central forehead

!! Stage 1Stage 1!! Prerosacea plus:Prerosacea plus:

!! TelangiectasiasTelangiectasias –– permanent dilation of small permanent dilation of small BVsBVs!! Prominent sebaceous glandsProminent sebaceous glands

Recognizing RosaceaRecognizing Rosacea• Early signs are

vascular• Flushing, erythema,

and telangiectasias• Occur in an axial facial

distribution (forehead,cheeks, nose, chin)

• “butterfly” patternsimilar to SLE

• An overall oilyappearance to the skin

Recognizing RosaceaRecognizing Rosacea!! Stage 2Stage 2

!! Stage 1 plus:Stage 1 plus:!!EdemaEdema!!Papules/Pustules Papules/Pustules ""!!Enlarged poresEnlarged pores

!! Stage 3Stage 3!! Stage 2 plus:Stage 2 plus:

!!Tissue hyperplasia (Tissue hyperplasia (phymasphymas))!!Rhinophyma-hypertrophy of sebaceousRhinophyma-hypertrophy of sebaceous

glands of the noseglands of the nose

Recognizing RosaceaRecognizing Rosacea

• Later stages areinflammatory• In top patients, there is

early sebaceous glandhypertrophy andrhinophyma.

• In lower slide, notepapules, pustules, lidinvolvement andrhinophyma.

Questions andQuestions andComments?Comments?

Making the DiagnosisMaking the Diagnosis!! Rosacea is a clinical diagnosis that does not require labsRosacea is a clinical diagnosis that does not require labs

or pathology specimensor pathology specimens!! Differential DiagnosesDifferential Diagnoses

!! Acne Acne vulgarisvulgaris!! AdultAdult!! Drug-inducedDrug-induced

!! Contact dermatitisContact dermatitis!! Seborrheic dermatitisSeborrheic dermatitis!! EczemaEczema!! SarcoidosisSarcoidosis!! Lupus: SLE, subacute, chronicLupus: SLE, subacute, chronic!! Perioral dermatitisPerioral dermatitis!! Drug-induced photosensitivity reaction (Drug-induced photosensitivity reaction (TetracyclinesTetracyclines))

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Rosacea Rosacea ““ScorecardScorecard”” for Clinicians for Clinicians

Order at http://www.rosacea.org/physicians/scoreindex.html

Subtypes of RosaceaSubtypes of Rosacea!! There are 4 different subtypes:There are 4 different subtypes:

!! Erythematotelangiectatic rosaceaErythematotelangiectatic rosacea!! Papulopustular rosaceaPapulopustular rosacea!! Phymatous rosaceaPhymatous rosacea!! Ocular rosaceaOcular rosacea

!! Many patients have characteristics of Many patients have characteristics of more thanmore thanoneone subtype! subtype!

Subtypes of RosaceaSubtypes of Rosacea!! Subtype 1Subtype 1

!! ErythematotelangiectaticErythematotelangiectatic!! FlushingFlushing!! Persistent facial rednessPersistent facial redness

!! Subtype 2Subtype 2!! PapulopustularPapulopustular!! Bumps (papules) and/orBumps (papules) and/or

pimples (pustules)pimples (pustules)!! Some may also experienceSome may also experience

raised red patchesraised red patches(plaques)(plaques)

Rosacea.org

SubtypesSubtypes

!! Subtype 3Subtype 3!! Phymatous rosaceaPhymatous rosacea!! Enlargement of theEnlargement of the

nose (excess tissue)nose (excess tissue)!! rhinophymarhinophyma

!! Subtype 4Subtype 4!! Ocular rosaceaOcular rosacea

Ocular Ocular RosaceaRosacea!! Ocular Ocular RosaceaRosacea

! Ocular signs and symptoms may occur beforeskin manifestations in up to 20%!

! Main symptoms are foreign-body sensation,burning and stinging.

!! Etiology is inflammation from StaphlococcusEtiology is inflammation from Staphlococcusexotoxins.exotoxins.

!! Eye signs are secondary to the inflammatoryEye signs are secondary to the inflammatoryskin condition.skin condition.

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The Ocular SurfaceThe Ocular Surface

Picture from Kanski’s Clinical Ophthalmology Fourth Edition

Dry Eye and RosaceaDry Eye and Rosacea

!! National Rosacea Society SurveyNational Rosacea Society Survey!! 1,780 rosacea patients reporting1,780 rosacea patients reporting

ocular symptomsocular symptoms!! 95 percent said eyes felt dry, gritty,95 percent said eyes felt dry, gritty,

or irritated.or irritated.!! Of these, only 28 percent reportedOf these, only 28 percent reported

being formally diagnosed with ocularbeing formally diagnosed with ocularrosacea.rosacea.

Meibomian Meibomian GlandsGlands


!! Holocrine Holocrine glands thatglands thatsupply lipids.supply lipids.

!! External oily layer ofExternal oily layer oftear film.tear film.

!! Alterations in lipidsAlterations in lipidscause MGD.cause MGD.

Ocular Ocular RosaceaRosacea

!! Ocular Surface Inflammatory DiseaseOcular Surface Inflammatory Diseaseis the main complication *is the main complication *

!! Signs include dry eye, Signs include dry eye, telangiectasiaof lid margins, conjunctivitis,blepharitis, recurrent chalazia andhordeola, meibomitis meibomitis (MGD), (MGD), keratitiskeratitis..

!! MeibomitisMeibomitis!! Inflammation of theInflammation of the

meibomian orificesmeibomian orifices!! When severe, presents as aWhen severe, presents as a

thick, viscous plugging ofthick, viscous plugging ofmaterial material ““toothpastetoothpaste””

!! Increases tear Increases tear evapevap!! Increases tear Increases tear osmolarityosmolarity

!! In In RosaceaRosacea, MGD is, MGD isoften chronic andoften chronic andunrelenting.unrelenting.

Ocular RosaceaOcular Rosacea

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Mixed Ant. Mixed Ant. Blepharitis Blepharitis and MGDand MGD


HordeolaHordeola!! Local infection ofLocal infection of

meibomian glands ormeibomian glands orglands of Zeiss or Mollglands of Zeiss or Moll

!! Inflamed, painful areaInflamed, painful area!! A localized, A localized, externalexternal

lesion or a deeper, less-lesion or a deeper, less-circumscribed circumscribed internalinternal

!! Staph species are usualStaph species are usualsuspectssuspects

!! Chalazia also commonChalazia also commonin rosaceain rosacea


!! ConjunctivitisConjunctivitis!! Usually chronic, bacterialUsually chronic, bacterial!! Diffuse hyperemia, lid signs ofDiffuse hyperemia, lid signs of

bleph/MGDbleph/MGD!! PseudomembranePseudomembrane or even trueor even true

membranemembrane!! fibrinous fibrinous inflammatory inflammatory exudateexudate

!! secreted by invading microorganisms or ocularsecreted by invading microorganisms or oculartissuestissues

!! permeates the superficial layers of permeates the superficial layers of conjunctivalconjunctivalepitheliumepithelium

• Severe, active rosaceablepharo-kerato-conjunctivitis "

• Note lid inflammation,interpalpebral conj.hyperemia, cornealvascularization andinfiltrates.

• Conjunctivalpseudomembrane "


Ocular Ocular RosaceaRosacea

!! Corneal findings:Corneal findings:!! EarlyEarly

!!PEK in inferior 1/3PEK in inferior 1/3!! ModerateModerate

!!Marginal infiltrate (usually sterile)Marginal infiltrate (usually sterile)!! AdvancedAdvanced!! Neovascularization Neovascularization "" opacificationopacification --> -->Thinning Thinning "" ulceration ulceration "" perforation perforation

(Left)

Punctate corneal epithelialbreakdown and macro-ulceration.

Chronic Rosacea KeratopathyChronic Rosacea Keratopathy

(Above)Neovascularization " opacification

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Managing the Symptoms andManaging the Symptoms andEmotions of Emotions of RosaceaRosacea

!! Therapeutic strategy depends uponTherapeutic strategy depends uponSubtype and Stage (severity) ofSubtype and Stage (severity) ofdisease.disease.

!! Medical therapyMedical therapy!! TetracyclinesTetracyclines- decrease bacterial lipase- decrease bacterial lipase""improve solubility of sebaceous glandimprove solubility of sebaceous glandsecretionssecretions!!DoxycyclineDoxycycline 100 mg bid x 6 wk, then 100 mg bid x 6 wk, then qdqd

TetracyclinesTetracyclines

!! When longer-term therapy is needed:When longer-term therapy is needed:!! PeriostatPeriostat ((doxycyclinedoxycycline hyclatehyclate))

!! 20mg tab20mg tab!! QdQd or bid or bid!! Initially developed for Initially developed for periodontitisperiodontitis!! Now available as generic!Now available as generic!

!! OraceaOracea ( (doxycyclinedoxycycline monohydrate) monohydrate)

Periostat

Oracea

Periostat((doxycyclinedoxycyclinehyclatehyclate))

Oracea((doxycyclinedoxycyclinemonohydrate)monohydrate)

OraceaOracea! FDA approved in 4/2006 Oracea (doxycycline,

CollaGenex Pharmaceuticals) to treatinflammatory rosacea in adults.

!! 1st drug approved for 1st drug approved for Papulopustular Rosacea only

! Contains 30mg of immediate-release medication and10mg delayed-release medication in capsule

! Exhibits anti-inflammatory and not antimicrobialproperties, so no drug resistance issues

OraceaOracea: The Evidence: The Evidence! Results of Phase 4 Study Evaluating Effects of

Oracea in Combo w/ MetroGel(R) (metronidazolegel), 1%

! Presented at Annual Meeting of the AAD

! Patients in the Oracea + MetroGel GroupExperienced a Mean Reduction of 13.9Inflammatory Lesions Compared to 8.5 in thePlacebo + MetroGel Group

! Oracea has not yet been studied specifically forocular rosacea.

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Special CautionsSpecial Cautions!! When are When are tetracyclines tetracyclines contraindicated ?contraindicated ?

!! ChildrenChildren!! Pregnant/nursing mothersPregnant/nursing mothers!! Poor kidney functionPoor kidney function

!! Side effects/complications of Side effects/complications of tetracyclinestetracyclines!! GI upsetGI upset!! PhotosensitivityPhotosensitivity!! Pseudotumor cerebriPseudotumor cerebri**

!! Antacids, dairy make drug less effectiveAntacids, dairy make drug less effective!! Rx. Erythromycin as an alternativeRx. Erythromycin as an alternative

SIDE EFFECTSSIDE EFFECTS

DOXYCYCLINEDOXYCYCLINE!! Side effectsSide effects

!! PhotosensitivityPhotosensitivity!! Pseudotumor cerebriPseudotumor cerebri, blood , blood dyscrasiasdyscrasias!! Decreased bone growth, teeth discolorationDecreased bone growth, teeth discoloration

!! ContraindicationsContraindications!! Under age 8Under age 8!! PregnancyPregnancy!! NursingNursing!! Liver dysfunctionLiver dysfunction

DOXYCYCLINEDOXYCYCLINE!! Pregnancy / nursingPregnancy / nursing

!! CategoryCategory DD!! Positive evidence of risk to fetusPositive evidence of risk to fetus

!! Does enter breast milkDoes enter breast milk!! ChildrenChildren

!! Okay over age 8 (2-5 mg/kg/day up to 200 mg)Okay over age 8 (2-5 mg/kg/day up to 200 mg)!! Miscellaneous informationMiscellaneous information

!! Take with or without mealsTake with or without meals!! With food may reduce absorption by 20%With food may reduce absorption by 20%!! Without food may cause Without food may cause gi gi irritationirritation

!! Oral contraceptives may not workOral contraceptives may not work!! Take all that is prescribed even if feel betterTake all that is prescribed even if feel better!! Iron, multivitamins, Ca, antacids, laxatives within 2 hours may make lessIron, multivitamins, Ca, antacids, laxatives within 2 hours may make less

effectiveeffective

DOXYCYCLINEDOXYCYCLINE!! ALTERNATIVES ALTERNATIVES (CHECK DOSING / SIDE(CHECK DOSING / SIDE

EFFECTS)EFFECTS)

!! ERYTHROMYCINERYTHROMYCIN!! TETRACYCLINE / MINOCYCLINETETRACYCLINE / MINOCYCLINE

!! SAME MECHANISM, USE CAUTIONSAME MECHANISM, USE CAUTION


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Medical TherapyMedical Therapy!! Metronidazole- Metronidazole- antimicrobial, anti-inflammatory,antimicrobial, anti-inflammatory,

and immunosuppressive propertiesand immunosuppressive properties!! Oral and Topical forms (use on Oral and Topical forms (use on lids/adnexalids/adnexa?)?)

!! .75%-1% gel, cream.75%-1% gel, cream!! Effective for inflammatory lesions, not Effective for inflammatory lesions, not telangiectasiastelangiectasias

!! Corticosteroid lotion, such as Corticosteroid lotion, such as DesonideDesonide!! Retinoids- Retinoids- Vitamin A derivatives, suppressVitamin A derivatives, suppress

sebum productionsebum production!! For severe or recurrent For severe or recurrent rosacearosacea

!! Isotretinoin Isotretinoin .5-1 mg/kg/day (.5-1 mg/kg/day (AccutaneAccutane))

!! H-2 Antagonists- combat H. pyloriH-2 Antagonists- combat H. pylori

AzA AzA GelGel

!! 15% 15% azelaic azelaic acid gelacid gel!! Apply bid forApply bid for

moderatemoderatepapulopustular papulopustular form.form.

Treatment of RosaceaTreatment of Rosacea!! Surgical therapySurgical therapy

!! Pulsed-dye laser for Subtype 1 (pictured below)Pulsed-dye laser for Subtype 1 (pictured below)! Surgical Ablation! Electrocautery! CO-2 laser (removes hypertrophied tissue to reshape

nose)

Photodynamic TherapyPhotodynamic Therapy

Step 2: BLU-U Blue Light PhotodynamicTherapy Illuminator (BLU-U).

Step 1: Application of Levulan KerastickTopical Solution (5-aminolevulinic acid, 20%)

Photodynamic TherapyPhotodynamic Therapy Intense Pulsed LightIntense Pulsed Light!! High-intensity pulses of aHigh-intensity pulses of a

broad wavelength (515-1200broad wavelength (515-1200nm) of light deliver energy tonm) of light deliver energy tothe skin.the skin.

!! Off-label, used to treatOff-label, used to treatdispigmentationdispigmentation..

!! Constricts Constricts BVsBVs, generates, generatesheatheat

!! Liquifies meibomianLiquifies meibomiansecretionssecretions

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New Therapy:New Therapy:Intense Pulsed Light (IPL)Intense Pulsed Light (IPL) Treating the PersonTreating the Person

Educate and CounselEducate and Counsel!! Avoid trigger foods,Avoid trigger foods,

sunlight, sunscreensunlight, sunscreen!! Reassurance, self-Reassurance, self-

esteemesteem!! DepressionDepression!! AAnxietynxiety

!! Stress managementStress management

Ocular Ocular Rosacea Rosacea TreatmentsTreatments Ocular Rosacea TreatmentOcular Rosacea Treatment!! Treatment may include:Treatment may include:

!! Lid hygieneLid hygiene!! baby shampoo or baby shampoo or pre-moistened padspre-moistened pads!! hot compress hot compress!! saline soakssaline soaks

!! Lubricate: AT 1 Lubricate: AT 1 gt gt qid-q2h (Soothe XP, qid-q2h (Soothe XP, SystaneSystaneBal)Bal)

!! Topical medsTopical meds!! ““lightlight”” steroids: beware of rebound steroids: beware of rebound!! AB, AB/Steroid combosAB, AB/Steroid combos!! Restasis® (cyclosporine ophthalmic emulsion 0.05%)Restasis® (cyclosporine ophthalmic emulsion 0.05%)

Ocular Ocular Rosacea Rosacea ManagementManagement

OR +

Ocular Ocular Rosacea Rosacea TreatmentTreatment

!! Treatment may include:Treatment may include:!! Omega-3 supplementsOmega-3 supplements!! Systemic meds: Systemic meds: doxycyclinedoxycycline!! Co-management w/PCPCo-management w/PCP!! Dermatology consult for systemicDermatology consult for systemic

managementmanagement!! Surgical treatment for severe cornealSurgical treatment for severe corneal

complicationscomplications

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Combination TherapyCombination Therapy

Cleeravue-M Kit

50mg minocyclinetabs

+

SteriLid

linalool and tea treeoil kill Demodex

!! Meibomitis Meibomitis (MGD)(MGD)!! Mild-moderateMild-moderate

!! Warm compress, saline scrubs, in-Warm compress, saline scrubs, in-office expressionoffice expression

!! ModerateModerate!! Add Topical AB/steroidAdd Topical AB/steroid

!! 1gt 1gt qid qid x 1-2 wkx 1-2 wk

!! SevereSevere!! Add Add po Doxycyclinepo Doxycycline!! 100 mg 100 mg po po bid x 4-6 wks, then taperbid x 4-6 wks, then taper

slowly as you would a steroid slowly as you would a steroid b/c b/c this isthis isinlflammatoryinlflammatory Dx Dx..

!! May need May need maintainance maintainance dose (20-50dose (20-50mg mg qdqd) long-term) long-term

Ocular Ocular Rosacea Rosacea TreatmentTreatment

Meibomian Meibomian DiseaseDisease!! Altered MGAltered MG

secretionssecretions causecauseabnormal tear filmabnormal tear filmlipids.lipids.

!! This results inThis results ininflammation,inflammation,irritation.irritation.

Ophthalmic Ophthalmic AzithromycinAzithromycin

!! Azithromycin Azithromycin 1% sol1% sol!! Macrolide Macrolide ABAB

!! Broad-spectrumBroad-spectrum!! Anti-inflammatoryAnti-inflammatory

!! Bid dosingBid dosing!! Approved for children >1Approved for children >1

y/oy/o!! ApprovedApproved for for bact bact conjconj

!! In trials for MGD, DESIn trials for MGD, DES

AzaSite AzaSite modifies MG secretionsmodifies MG secretions!! Azithromycin Azithromycin 1% sol1% sol

!! 17 patients17 patients!! qd qd dosing xdosing x 4 wks4 wks

!! Structure and behavior ofStructure and behavior ofMG secretionsMG secretions alteredalteredtoward that of normaltoward that of normalsecretionssecretions

!! Avg Avg TBUT improved fromTBUT improved from6.0 to 10.27 sec6.0 to 10.27 sec

!! Subjective improvementSubjective improvement!! FoulksFoulks, 2009, 2009

!! In MGD, In MGD, Azasite Azasite + WC+ WCoutperformed WC alone.outperformed WC alone.

Mild-Moderate InflammationMild-Moderate Inflammation!! Loteprednol Loteprednol etabonate 0.5%etabonate 0.5%

((LotemaxLotemax))!! ophthalmic suspensionophthalmic suspension!! effective against moderateeffective against moderate

ocular inflammationocular inflammation!! effective in treating post-effective in treating post-

operative inflammationoperative inflammation!! relatively small tendency torelatively small tendency to

increase IOPincrease IOP!! frequently usedfrequently used ““off-labeloff-label”” in in

DESDES!! Short-term therapy in ocularShort-term therapy in ocular

rosacearosacea

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New SteroidNew Steroid!! Difluprednate Difluprednate .05% emulsion.05% emulsion

!! No shakingNo shaking!! Less frequent dosingLess frequent dosing

!! Derived from Derived from prednisoloneprednisolone!! FDA indication for FDA indication for post-Sxpost-Sx..

inflamminflamm, pain, pain

Ocular Ocular Rosacea Rosacea TreatmentTreatment!! BlepharitisBlepharitis

!! Mild-moderateMild-moderate!! Amenable to warm compress,Amenable to warm compress,

saline scrubssaline scrubs!! Baby shampoo scrubsBaby shampoo scrubs

!! 2-3 wks max2-3 wks max!! ModerateModerate

!! Add Topical AB/steroid Add Topical AB/steroid UngUng!! hs hs x 1-2 wkx 1-2 wk

!! SevereSevere!! Increase AB/steroid Increase AB/steroid Ung Ung to bidto bid!! Add Add po Doxycyclinepo Doxycycline!! 100 mg 100 mg po po bid x 4wks, thenbid x 4wks, then

tapertaper

Steroid-Antibiotic CombinationsSteroid-Antibiotic Combinations

!! These medications areThese medications are steroids steroids and thereforeand thereforecause the same side effectscause the same side effects

!! Primary usePrimary use is for control of is for control of inflammationinflammation!! Provides Provides antibacterial prophylaxisantibacterial prophylaxis while treating while treating

the ocular inflammationthe ocular inflammation!! Examples:Examples:

!! Adenoviral KC Adenoviral KC w/sigw/sig. . epi epi stainingstaining!! Marginal K infiltrateMarginal K infiltrate

Ocular Ocular Rosacea Rosacea TreatmentTreatment!! External External HordeolumHordeolum

!! Warm compress, saline scrubs,Warm compress, saline scrubs,in-office expressionin-office expression

!! Topical AB or AB/steroidTopical AB or AB/steroid!! 1gt 1gt qid qid x 1-2 wkx 1-2 wk

!! Internal Internal HordeolumHordeolum!! Add broad-spectrum Add broad-spectrum po po ABAB

!! Effective against Effective against staph/strepstaph/strep!! DoxycyclineDoxycycline

!! 100 mg 100 mg po po bid x 7-10 daysbid x 7-10 days!! Or, Or, CephalexinCephalexin

!! 250 mg 250 mg po qid po qid x 7-10 daysx 7-10 days

Ocular Ocular Rosacea Rosacea TreatmentTreatment!! Bacterial ConjunctivitisBacterial Conjunctivitis

! Topical AB or AB/steroid! 1gt qid x 7-10 days! AB/steroid combo best if marked inflammation

present!! TobradexTobradex ( (tobramycin/dexamethtobramycin/dexameth) or ) or ZyletZylet

((tobramycin/lotepredtobramycin/lotepred))!! Moderate/Severe presentation may requireModerate/Severe presentation may require

topical topical fluorquinolonefluorquinolone 1 1 gtgt q1-2h for 2-3 days, q1-2h for 2-3 days,then, reduce to then, reduce to qidqid..!! MoxifloxacinMoxifloxacin ( (VigamoxVigamox) or ) or gatifloxacingatifloxacin ( (ZymarZymar))

Ophthalmic Azithromycin:Ophthalmic Azithromycin:

!! AzaSiteAzaSite®® pairs DuraSite pairs DuraSite®®

drug delivery vehicle withdrug delivery vehicle withazithromycin (1%)azithromycin (1%)!! Enhances bioavailabilityEnhances bioavailability

!! Has both antibiotic andHas both antibiotic andanti-inflammanti-inflamm. properties. properties

16

New New FluorquinoloneFluorquinolone

!! Besifloxacin Besifloxacin .6%.6% suspsusp!! FDA indication forFDA indication for

bactbact. conj.. conj.!! Durasite Durasite vehiclevehicle

!! Lengthens ocularLengthens ocularsurface contact timesurface contact time

54-year-old White Male54-year-old White Male

Photo Courtesy of A. Kabat

Back to our caseBack to our case……!! 54-year-old White Male54-year-old White Male! Based upon medical history and appearance, a

diagnosis of ocular rosacea was established.! We initiated treatment with warm compresses,

non-preserved artificial tears and oraldoxycycline (100 mg BID for six weeks, thenslowly tapered).

! The patient was counseled on avoiding triggers,such as sunlight, spicy foods, hot beverages andstress.

Ocular Ocular Rosacea Rosacea ManagementManagement

OR +

Back to our caseBack to our case……

! A follow-up examination 8 weeks latershowed near-complete resolution of signsand symptoms.

! The patient has regular dermatology visitsand remains on Oracea and topical skintherapy.

WhatWhat’’s New?s New?

!! TobraDex TobraDex STST ( (tobramycin/dexmethasonetobramycin/dexmethasoneophthalmic suspension) 0.3/0.05%.ophthalmic suspension) 0.3/0.05%.

!! Indicated for inflammatory ocular conditions forIndicated for inflammatory ocular conditions forwhich a corticosteroid is indicated and wherewhich a corticosteroid is indicated and wherebacterial infection or risk for infection exists.bacterial infection or risk for infection exists.

!! Formulated with a new vehicle to enhanceFormulated with a new vehicle to enhancebioavailability to targeted tissues.bioavailability to targeted tissues.

!! UsefulUseful for for blepharitis/MGDblepharitis/MGD

17


Dry Eye and Dry Eye and RosaceaRosacea

Lacrimal Lacrimal Function UnitFunction Unit! Dry conditions on ocular

surface stimulate sensorynerves, innervating corneaand conjunctiva.

! These stimulatesecretomotor nerves, whichtrigger tear secretion bylacrimal glands.

! This feedback systemmaintains a stable,refreshed tear film over theocular surface.

Normal Tear FilmNormal Tear Film Dry Eye and Dry Eye and RosaceaRosacea

!! Theories for Pathogenesis of DES inTheories for Pathogenesis of DES inRosaceaRosacea!! Evaporative loss from MGDEvaporative loss from MGD!! Increased Increased IL-1 alphaIL-1 alpha concentration in tears of concentration in tears of

rosacea rosacea patientspatients!! Greater Greater matrix metalloproteinase matrix metalloproteinase activityactivity

!! Tetracylclines Tetracylclines have an inhibitory effect onhave an inhibitory effect onboth of these factorsboth of these factors (IL-1, MPP)(IL-1, MPP)

18

DES inDES in RosaceaRosacea DES in DES in RosaceaRosacea

!! Refractive SurgeryRefractive Surgerymay trigger ormay trigger orexacerbate DES inexacerbate DES inRosacea Rosacea patients.patients.

Dry Eye Therapy in RosaceaDry Eye Therapy in Rosacea!! Is there a strategy?Is there a strategy?

!! Address Address blepharitisblepharitis, , meibomitis meibomitis if also presentif also present!! Supportive therapy for mild symptoms/signsSupportive therapy for mild symptoms/signs

!! Humidifier at home or in work environmentHumidifier at home or in work environment!! Ocular surface treatment with tear supplements upOcular surface treatment with tear supplements up

to q2hto q2h!! Nutritional SupportNutritional Support

!! Omega-3 fatty acids (salmon, sardines)Omega-3 fatty acids (salmon, sardines)!! Flaxseed oilFlaxseed oil!! Water intakeWater intake

Soothe Soothe XXP EmollientP Emollient

!! RestorylRestoryl!! Meta-stable emulsionMeta-stable emulsion!! Increases lipid layerIncreases lipid layer!! Highly purified mineralHighly purified mineral

oilsoils!! Drakeol-15Drakeol-15!! Drakeol-35Drakeol-35

!! PolyhexamethylenePolyhexamethylenebiguanide-preservedbiguanide-preserved

WHATWHAT’’S NEW?S NEW?!! Systane Systane Balance (Balance (AlconAlcon))!! For evaporative dry eyeFor evaporative dry eye

secondary to MGDsecondary to MGD!! Enhancement of lipidEnhancement of lipid

layerlayer!! Propylene Glycol 0.6%Propylene Glycol 0.6%!! Mineral oilsMineral oils!! Oil inOil in water emulsionwater emulsion!! LipiTech LipiTech System andSystem and

demulcentdemulcent

Omega-3sOmega-3s

!! DecreaseDecreaseinflammationinflammation

!! Decrease apoptosisDecrease apoptosis!! IncreaseIncrease teartear

secretionsecretion

19

Dry Eye Therapy in RosaceaDry Eye Therapy in Rosacea!! For moderate symptoms/signs (or if noFor moderate symptoms/signs (or if no

improvement improvement w/supportive Txw/supportive Tx.).)!! Add topical anti-inflammatory therapyAdd topical anti-inflammatory therapy

!! RestasisRestasis® (cyclosporine A 0.05% ophthalmic® (cyclosporine A 0.05% ophthalmicemulsion)emulsion)

!! ““lightlight”” topical steroids trial topical steroids trial!! Flarex Flarex (FML)(FML)!! LotemaxLotemax!! Pred-mildPred-mild

Dry Eye TreatmentDry Eye Treatment

!! Cyclosporine 0.05% (Cyclosporine 0.05% (RestasisRestasis))!! Ophthalmic emulsionOphthalmic emulsion!! Provides anti-inflammatory effects for ocularProvides anti-inflammatory effects for ocular

surface tissues and lacrimal glandssurface tissues and lacrimal glands!! Requires Requires 3-4 months3-4 months of continuous use to of continuous use to

reach clinically significant effects and up to 6reach clinically significant effects and up to 6months to achieve full therapeutic effectsmonths to achieve full therapeutic effects

Lissamine Lissamine Green StainingGreen Staining Dry Eye Therapy in RosaceaDry Eye Therapy in Rosacea!! If no improvement after adding topical anti-If no improvement after adding topical anti-

inflammatory agents:inflammatory agents:!! po Tetracyclines po Tetracyclines prescribedprescribed

!! earlier than for earlier than for non-rosacea non-rosacea DES*DES*!! Dosage and duration similar to that for otherDosage and duration similar to that for other sub-sub-

typestypes!! Remember to taper or switch to Remember to taper or switch to OraceaOracea

!! Lacrimal/punctal Lacrimal/punctal occlusionocclusion!! Only after inflammation is controlled (usually 4 wksOnly after inflammation is controlled (usually 4 wks

after starting anti-inflammatory therapy)after starting anti-inflammatory therapy)!! Plugs or Plugs or cauterycautery

Dry Eye Therapy in RosaceaDry Eye Therapy in Rosacea!! If still no improvement or patient initiallyIf still no improvement or patient initially

presents with severe symptoms/signs (4+presents with severe symptoms/signs (4+PEK, erosions, PEK, erosions, conjunctival conjunctival scarring):scarring):!! po Tetracyclinespo Tetracyclines

! Corneal subspecialty consult!! po po CyclosporineCyclosporine!! TarsorrhaphyTarsorrhaphy!! Amniotic membrane Amniotic membrane TxTx

Review of Key PointsReview of Key Points

!! Skin is a protective, regulatory, immune,Skin is a protective, regulatory, immune,and sensory organ.and sensory organ.

!! Rosacea Rosacea is a chronic condition withis a chronic condition withexacerbations and remissions.exacerbations and remissions.!! A number of exogenous factors can trigger anA number of exogenous factors can trigger an

acute episode.acute episode.!! Ocular Ocular Rosacea Rosacea is a distinct subtypeis a distinct subtype withwith

surface inflammatory diseasesurface inflammatory disease as its most as its mostcommon clinical feature.common clinical feature.

20

Now what?Now what?

!! The Challenge:The Challenge:!! Effectively diagnose and manage/co-manageEffectively diagnose and manage/co-manage

acute and chronicacute and chronic features of features of rosacearosacea..!! Effectively diagnose and treat ocular Effectively diagnose and treat ocular rosacearosacea..!! Communicate and coordinate care with theCommunicate and coordinate care with the

appropriate physician (primary care and/orappropriate physician (primary care and/ordermatologist) in a timely and effective manner,dermatologist) in a timely and effective manner,resulting in resulting in improved patient outcomes.improved patient outcomes.


Resources for Patients and DoctorsResources for Patients and Doctors! Browning DJ, Proia AD. Ocular rosacea. Surv

Ophthalmol 1986 Nov-Dec;31(3):145-58. Vol. No:143:11Issue: 11/15/2006

!! J Am Acad Dermatol 2002;46:584-7. StandardJ Am Acad Dermatol 2002;46:584-7. StandardClassification of RosaceaClassification of Rosacea

!! National Rosacea Society National Rosacea Society http://www.rosacea.org/http://www.rosacea.org/!! Stevens G, Lemp M. Acne rosacea. In: T Weingeist , DStevens G, Lemp M. Acne rosacea. In: T Weingeist , D

Gould. The Eye in Systemic Disease. Philadelphia:Gould. The Eye in Systemic Disease. Philadelphia:Lippincott, 1990.Lippincott, 1990.

!! Pizzimenti Pizzimenti JJ, JJ, Pelino Pelino CJ. Soothe the burn of ocularCJ. Soothe the burn of ocularrosacearosacea. Review of Optometry. 2009. Review of Optometry. 2009

The Lid and AdnexaThe Lid and Adnexa

Types of Dermatologic Types of Dermatologic DxDx..

!! Allergic: contact dermatitisAllergic: contact dermatitis!! Inflammatory: Inflammatory: rosacearosacea!! Infectious: HSV, HZVInfectious: HSV, HZV!! NeoplasticNeoplastic

!! BenignBenign!! Pre-malignantPre-malignant!! MalignantMalignant

Identifying Signs of Lid andIdentifying Signs of Lid andAdnexa DiseaseAdnexa Disease

!! Signs of allergicSigns of allergicdiseasedisease

!! Signs of atopicSigns of atopicdiseasedisease

!! Signs of otherSigns of otherdiseasedisease!! InfectiousInfectious!! InflammatoryInflammatory!! StructuralStructural

21

Case: HistoryCase: History

!! A healthy 38 y/o WF presented with aA healthy 38 y/o WF presented with atender patch of small vesicles on thetender patch of small vesicles on thelower left eyelid and surrounding skin.lower left eyelid and surrounding skin.

!! Itch, rednessItch, redness!! Sudden onset, 2 day durationSudden onset, 2 day duration!! May have rubbed lids after yard work.May have rubbed lids after yard work.

38 year old WF38 year old WFSubjectiveSubjective

!! Ocular History: unremarkableOcular History: unremarkable!! Medical History: unremarkableMedical History: unremarkable!! Family Ocular History: + AMD (mother)Family Ocular History: + AMD (mother)!! Allergies: none knownAllergies: none known!! Topical Meds: artificial tearsTopical Meds: artificial tears

ObjectiveObjective Findings

! VA: c Rx OD 20/25 OS 20/30 PH 20/25

! Pupils: (-)APD, PERRLA

! EOMS: Smooth / Full

! IOP: 12 mm Hg OD, 14 mmHg OS

! CF: Full OD/OS

! Anterior Chamber, Lens, Vitreous: Clear OD/OS

Day 1Day 1

BiomicroscopyBiomicroscopy

!! Diffuse pustules with erythemous base onDiffuse pustules with erythemous base oninferior lid OSinferior lid OS

!! Grade 1 follicles lower palpebralGrade 1 follicles lower palpebralconjunctiva conjunctiva OUOU

! Cornea uninvolved

AssessmentAssessment

!! Differential DiagnosisDifferential Diagnosis

!! Atopic Contact Blepharitis/DermatitisAtopic Contact Blepharitis/Dermatitis!! Herpes Simplex Blepharitis/DermatitisHerpes Simplex Blepharitis/Dermatitis!! Herpes ZosterHerpes Zoster

22

Atopic Contact Dermatitis

Herpes Zoster

Differential DiagnosisDifferential Diagnosis Nail Varnish AllergyNail Varnish Allergy

Differential DiagnosisDifferential DiagnosisHerpes Simplex Blepharitis/DermatitisHerpes Simplex Blepharitis/Dermatitis

Initial ManagementInitial Management

!! TobradexTobradex!! tobramycin 0.3%/dexamethasone 0.1%tobramycin 0.3%/dexamethasone 0.1%

ophthalmic ointment! Apply lightly to affected tissues bid

! Benadryl (diphenhydramine) at bedtime! Cool compresses prn! Recheck in 2 days

Day 3- Initial Follow-upDay 3- Initial Follow-upPreseptal Cellulitis

Day 3- Initial Follow-upDay 3- Initial Follow-up2+ Follicular Conjunctivitis

23

Re-assessmentRe-assessment

!! Herpes SimplexHerpes Simplex!! BlepharodermatitisBlepharodermatitis!! ConjunctivitisConjunctivitis

!! Associated Preseptal CellulitisAssociated Preseptal Cellulitis! Cornea uninvolved

New PlanNew Plan

!! D/C Tobradex ungD/C Tobradex ung!! Start Viroptic (trifluridine 1%) 1 gt OS 5X/dStart Viroptic (trifluridine 1%) 1 gt OS 5X/d!! Oral AntiviralOral Antiviral

!! AcyclovirAcyclovir!! 400mg 5x/d x 1wk400mg 5x/d x 1wk

Day 4

Pustular Blepharitis

Initial HSV Course Initial HSV Course

Day 7 Day 15

Day 21- ResolutionDay 21- ResolutionRecurrent Vesicular Blepharitis

Day 1

3 Months Later …

24

Fool me once Fool me once ……

!! AssessmentAssessment!! Recurrent HSV blepharitis and dermatitisRecurrent HSV blepharitis and dermatitis!! Test for immunocompromise (HIV)?Test for immunocompromise (HIV)?

!! PlanPlan!! Treatment of skin lesions with topical DenavirTreatment of skin lesions with topical Denavir

(penciclovir) cream.(penciclovir) cream.!! Trifluridine (Viroptic) 1% gtt qid to protectTrifluridine (Viroptic) 1% gtt qid to protect

cornea.cornea.

S/P Treatment With PenciclovirDay 5

PharmacologyPharmacology

!! Penciclovir 1%Penciclovir 1%!! Used to treat recurrent herpes simplexUsed to treat recurrent herpes simplex

infections of the face and lips in adultsinfections of the face and lips in adultswith healthy immune systems.with healthy immune systems.

!! Prevents viral r__________ by interferingPrevents viral r__________ by interferingwith activity of enzymes in DNA synthesis.with activity of enzymes in DNA synthesis.

PenciclovirPenciclovir

C10H15N5O3

Dosage And AdministrationDosage And Administration

!! Apply Denavir every 2 hours whileApply Denavir every 2 hours whileawake for 4 days.awake for 4 days.

!! Start treatment during HSV p_______Start treatment during HSV p_______or when lesions first appear. **or when lesions first appear. **

!! Not to be used on mucous membranes.Not to be used on mucous membranes.!! Our patient was instructed to useOur patient was instructed to use

Denavir on skin only, not on lidDenavir on skin only, not on lidmargins or in eye.margins or in eye.

Drug EfficacyDrug Efficacy

!! Penciclovir cream has not been directlyPenciclovir cream has not been directlycompared to acyclovir ung in controlledcompared to acyclovir ung in controlledstudies.studies.

!! Controlled studies have shown penciclovirControlled studies have shown penciclovirbut but not not acycolvir ung to be more effectiveacycolvir ung to be more effectivethan a placebo for recurrent HSV skinthan a placebo for recurrent HSV skinlesions.lesions.

25

Brief Discussion of HSV! The most common virus in humans**

! O_______ infection: generally HSV-1! Genital infection: generally HSV-2

! Transmission occurs by d_____ c______! Saliva or mouth contact! Contact with active lesions

! 1 week incubation period

Recurrent InfectionRecurrent Infection

! Occurs in 20-25% of HSV infections! Recurrence risk increases after 2 or more

presentations! Site of recurrence may be different than

the site of primary infection.!! e.g. initial keratitis re-occurs as blepharitise.g. initial keratitis re-occurs as blepharitis!! e.g. initial cold sore re-occurs as keratitise.g. initial cold sore re-occurs as keratitis


! Re-activating factors:____________________________________________________________________________________________________________________________________________


! Re-activating factors:! sunlight/UV exposure! trauma, surgery! extreme temperatures! Fever! corticosteroid use! infectious diseases! menstruation, pregnancy

Herpetic Eye Disease QuizHerpetic Eye Disease Quiz!! HEDS II investigators found that low-doseHEDS II investigators found that low-dose

oral acyclovir:oral acyclovir: a.a. was ineffective in preventing recurrentwas ineffective in preventing recurrent

HSV eye infection HSV eye infection b.b. reduced by 74% the probability that anyreduced by 74% the probability that any

form of HSV eye dx. would returnform of HSV eye dx. would returnc.c. reduced by 41% the probability that anyreduced by 41% the probability that any

form of HSV eye dx. would return form of HSV eye dx. would return

Herpetic Eye Disease QuizHerpetic Eye Disease Quiz!! HEDS II investigators found that low-doseHEDS II investigators found that low-dose

oral acyclovir:oral acyclovir: a.a. was ineffective in preventing recurrentwas ineffective in preventing recurrent

HSV eye infection HSV eye infection b.b. reduced by 74% the probability that anyreduced by 74% the probability that any

form of HSV eye dx. would returnform of HSV eye dx. would returnc.c. reduced by 41% the probability that anyreduced by 41% the probability that any

form of HSV eye dx. would returnform of HSV eye dx. would return

26

Take Home PointsTake Home Points

!! HSV blepharitis can masquerade asHSV blepharitis can masquerade asother atopic and infectious entities.other atopic and infectious entities.

!! Clinicians are able to offer a newClinicians are able to offer a newtherapeutic option that may hastentherapeutic option that may hastensymptomatic relief.symptomatic relief.

CASE #2CASE #2

!! HistoryHistory!! A 64 y/o white female presentedA 64 y/o white female presented

w/complaints of a slow-growing w/complaints of a slow-growing ““bumpbump”” on onmedial aspect of LL OS.medial aspect of LL OS.

!! Recent ulceration and bleeding of lesion.Recent ulceration and bleeding of lesion.!! Patient is a FL native, loves sailing.Patient is a FL native, loves sailing.!! Burns easily, tans poorlyBurns easily, tans poorly

Ulcerated NoduleUlcerated Nodule

!! OS Lower lidOS Lower lid

AssessmentAssessment

!! Differential DiagnosesDifferential Diagnoses

!! Basal Cell Carcinoma (BCC) *Basal Cell Carcinoma (BCC) *!! Squamous Cell Carcinoma (SCC)Squamous Cell Carcinoma (SCC)!! KeratoacanthomaKeratoacanthoma!! Actinic KeratosisActinic Keratosis

Nodular-ulcerative BCCNodular-ulcerative BCC

“Pearly” borders, ulcerated center

Squamous Cell Carcinoma!! Note NV patternNote NV pattern

!! Fast-changing, irregular, destroys lashesFast-changing, irregular, destroys lashes!! More likely to Mets than BCCMore likely to Mets than BCC

27

SCC with Anterior Orbit InvasionSCC with Anterior Orbit Invasion Conjunctiva Conjunctiva Squamous Squamous CellCell

KeratoacanthomaKeratoacanthoma•Clinical features:

•Abrupt onset

•Dome shape

•Ulcerated w/keratin

•Rapid growth (wks-months)

•Spontaneousinvolution (4-6 mon)

•Can resemble BCC

•pearly bordersRarely invasive, Mets

Actinic Keratosis•Pre-cancerous (malignant)

•Note flat, scaly, brown/gray appearance

•Slow-changing, r/o SCC, Melanoma

•Tx by excision or Efudex (5-fluorouracil)

Actinic Keratosis Actinic Keratosis PlanPlan

!! Photograph and measurePhotograph and measure!! Treated as nodular-ulcerative BCCTreated as nodular-ulcerative BCC!! Referral to Referral to oculoplasticsoculoplastics for excisional for excisional

biopsybiopsy!! A diagnosis of BCC was confirmedA diagnosis of BCC was confirmed!! RTC q 3 monRTC q 3 mon!! Limit sun exposure: visor, UV shieldLimit sun exposure: visor, UV shield

28

DiscussionDiscussion

!! BCCBCC!! 80-90% of all malignant lid tumors80-90% of all malignant lid tumors!! Most common form of skin CAMost common form of skin CA!! Lower lid--medial aspectLower lid--medial aspect!! Slow-growing, unlikely to metastasizeSlow-growing, unlikely to metastasize!! Risk factor: chronic sun exposureRisk factor: chronic sun exposure

!! May present as: nodular, nodular-May present as: nodular, nodular-ulcerative, superficial, or sclerosing formsulcerative, superficial, or sclerosing forms

Basal Cell CarcinomaBasal Cell Carcinoma

SuperficialPigmented BCC

Nodular BCC

Advanced Basal CellAdvanced Basal Cell

!! Sclerosing BCCSclerosing BCC

BCC of Eyebrow

The Lid MarginThe Lid Margin

Treatment of BCCTreatment of BCC!! ExcisionExcision!! MohsMohs’’ surgery surgery

!! Micrographic tumor excisionMicrographic tumor excision!! Computer assisted Computer assisted ““mapmap””!! Wide margin excision, frozen sectionsWide margin excision, frozen sections!! High cure rate w/minimal normal tissue lossHigh cure rate w/minimal normal tissue loss!! Large, nodular BCC, SCCLarge, nodular BCC, SCC

!! CryotherapyCryotherapy!! CauteryCautery

Mohs Micrographic Surgery

Step 1: Curettage

Curette away any friable tumor.

Step 2: Initial Excision

Make first excision with the bladebeveled at a 45 degree angle to theskin, just outside of the curetted area.

Round the edges of the excision.

Step Three: Tissue Dividing

Divide the tissue into quarters.

Step Four: Inking theQuartered Tissue Section

Color-ink tissue for orientation,mount on a slide in the cryostatand its horizontal knife.

Step 5: Prepare and readmicroscopic slides of eachtumor section.Return to excise more tissue.until we see cancer free lateraland deep margins.

29

Treatment of BCCTreatment of BCC

!! CryotherapyCryotherapy!! CauteryCautery!! MedicalMedical

!! Imiquad Imiquad topical cream: topical cream: Aldara Aldara (3M)(3M)!! Approved for superficial BCCApproved for superficial BCC!! Not Not for use on facefor use on face

ABCDEABCDE’’s of Tumorss of Tumors

## A = AsymmetryA = Asymmetry## B = BordersB = Borders

BleedingBleeding## C = Color changesC = Color changes

CCirculation from intrinsic irculation from intrinsic vascularityvascularity## D = DiameterD = Diameter## E = ElevationE = Elevation

Dacryocystis withPreseptal Cellulitis

Orbital Cellulitis

Preseptal Cellulitis

IV antibiotics

Oralantibiotics

Oral antibiotics

Periorbital Tumors Periorbital Tumors

## Syringomas-benignSyringomas-benignadnexal neoplasm formedadnexal neoplasm formedby well-differentiatedby well-differentiatedductal elementsductal elements

HidrocystomaHidrocystoma

## Cystic lesion of either the apocrine orCystic lesion of either the apocrine oreccrine sweat glandseccrine sweat glands

30

Insect Infestation Insect Infestation Questions and comments?Questions and comments?

The Last WordThe Last Word

“If at first you don'tsucceed, try again. Thenquit. There's no use beingfoolish about it.”

Thanks for spending yourprecious time with me!

Joe P.

[email protected]

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