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Dr. Edward Jaccoma, MD 1/26/25 Dr. Edward Jaccoma, MD 1/26/25

Eye Pain – what it can mean and what you can do to control or moderate it.

The perception of pain is a critical function of the nervous system. Children born without the ability to perceive pain tend not to live very long – not just because they can inadvertently inflict terrible injuries on themselves, but because the recognition of pain appears to be the necessary stimulus towards healing those injuries.

For those of you unfamiliar with Dr. Andrew Huberman, he is (unlike me) a neurobiologist and (much like me) an ophthalmologist, who I’ve drawn information from for this blog. I can point you towards his excellent podcast lectures with a link to one specific to this topic, here: https://www.hubermanlab.com/episode/essentials-control-pain-heal-faster-with-your-brain

I’ve posted several times on corneal pain and the role it can play in inflammation. A few posts key to this context can be found here: https://www.eyethera.com/blog/why-do-my-eyes-hurt-even-though-my-eye-doctor-says-they-look-fine and here: https://www.eyethera.com/blog/whats-new-in-2024-lets-focus-on-the-nerves?rq=pain

The point raised by Dr. Huberman that I think is vital to our understanding, is that inflammation is necessary to a healthy life – and therefore a good thing. What is also true, is that unbridled, continuous inflammation is not a good thing – and in the context of dry eye disease, it can be an undercurrent of the root causes of dry eye. Interfering with inflammation in the immediate, healing phase of an injury can dampen the pain response and if carefully applied – while it may draw out the time required to heal - it can also lead to a better result. This is especially true when it comes to many forms of eye surgery.

Glaucoma, cataract, corneal and retinal surgeries all trigger inflammation (and pain). Allowing the healing to occur as quickly as the body can drive it will often result in scarring and can undo the benefits of that surgery - or even result in severe complications (including chronic pain). I’ve already posted a substantial amount of information on inflammation (see: https://www.eyethera.com/search?q=inflammation&f_collectionId=5f1772c75adebf1951219a32 ) – but in the context of healing, we eye surgeons commonly prescribe strong steroids with slow tapering doses to keep a lid on inflammation and slow the healing to a rate consistent with our objectives for the surgery. When it comes to controlling inflammation associated with dry eyes, the same holds true. Our goal is to reduce inflammation and thereby reduce pain, without totally neutralizing the inflammation or the pain associated with this healing (so healing can be effective and complete)..

So, if inflammation is necessary for healing, then pain is a necessary part of that healing. And what is pain, other than a sensation? Well, pain typically begins with stimulation of nerve endings but ultimately is registered, interpreted and acted on, by the brain. Dr. Huberman points to the “top down” aspects of pain, when he uses illustrations such as the case of a construction worker who fell onto a 14-inch nail that skewered his boot. The worker was in such exquisite pain, that he couldn’t move his foot in any tiny direction and had to be carried by coworkers to an emergency clinic. After carefully cutting his boot away, it was determined that the nail had missed injuring his foot by passing between his toes. The perception that it had caused injury caused this severe pain. The “top” – or brain – was “causing” the pain from “down” (in this case, the foot).

Dr. Huberman goes on to relate the work on phantom pain, where an absent arm or leg may continue to cause debilitating pain. A brilliant scientist (Vilayanur Ramachandran: Professor of Psychology, University of California San Diego) constructed a box with mirrors which would allow a patient to put his or her remaining arm or leg in and then view it as if it were the missing appendage. Patients who had been in exquisite pain were often able to manipulate the “missing” arm or leg in the box and imagine it as “normal.” In less than a day, what had been unbearable pain for months or years was reduced to imperceptible – through “altered perception.” This ability of the brain to change how it functions, has been termed “neural plasticity.” Because this can happen from “top down,” it suggests that much of the pain we experience can be modified to become less disabling, by tapping into this ability for neural plasticity. My next post will be more about this!

Dr. Edward Jaccoma, MD 12/29/24 Dr. Edward Jaccoma, MD 12/29/24

An updated Index for 2024 - and a promise for more to come. Happy Holidays to you and yours!

An Updated Index Present.

Wrapping up 2024, I look forward to 2025 and the newer drugs, technologies and information/education coming in the New Year.

Dry eye disease is real, is often disabling, extremely prevalent and most of all, treatable. Sometimes it takes a village and almost always, it requires specialized help to get to, and ultimately deal with the many root causes. Too often we are led to “Band Aid” drops and treatments that can temporarily mask symptoms even as the disease progresses - leading to a bigger problem to eventually fix. Worse, some of these “Band Aids” can actually accelerate the progression they are otherwise covering up. Early detection and early intervention is currently the best answer and I hope my blogging points more sufferers to a better understanding and to better outcomes.

Winter is Coming. 10/21/24

A New Energy Option. 10/13/24

More Dry Eye News: And How Do I Know If I Have Dry Eye Disease?. 10/6/24

More on Unapproved and Possibly Dangerous Eye Drops. 09/29/24

A Patient's Plea for Help and What YOU Can Do to Help Them. 09/22/24

Study on Dry Eye Disease in Patients. 09/15/24

Rosacea Take Away "Pearls". 09/08/24

Rosacea and Dry Eyes Part 10. 08/04/24

Rosacea and Dry Eyes Part 9. 07/21/24

Rosacea and Dry Eyes Part 8. 07/07/24

Rosacea and Dry Eyes Part 7: The Mental Aspects of Rosacea. 06/30/24

Rosacea and Dry Eyes Part 6, The Tetracyclines. 06/16/24

Rosacea and Dry Eyes Part 5: How Did Rosacea Happen to Me? 06/09/24

Rosacea and Dry Eyes Part 4: Why Doctors Get Involved 05/27/24

Rosacea and Dry Eyes Part 3: Commonly Associated Skin Conditions. 05/19/24

Rosacea and Dry Eyes Part 2: How Common Is It? 05/12/24.

Rosacea and Dry Eyes, A Common Pairing that Needs Recognition Part 1. 04/29/24

News Update. 04/21/24

Making Tears Part 8. 04/14/24

Making Tears Part 7. 04/07/24

Making Tears Part 6. 03/31/24

Making Tears Part 5. 03/24/24

Making Tears Part 4. 03/10/24

Making Tears Part 3. 03/03/24

Making Tears Part 2. 02/25/24

Making Tears Part 1. 02/11/24

Where Do Tears Come From? 02/04/24

Why Rub Your Eye? 01/28/24

What's Up When the Sprinkler System "Dries Up"? 01/21/24More on Staining the Surface of a Dry Eye and What It Means

More for 2024. 01/14/24

What's New in 2024? Let's Focus on the Nerves! 01/Even Dry Eye Specialists Get the Blues. 07/24

Why Do My Eyes Feel Tired All the Time? 01/01/24

Happy Holidays and Getting to Know Dr. J. 12/25/23

More about CCH. 12/17/23

Eyedrops and Glaucoma. 12/10/23

Why Do My Eyes Hurt?... 12/03/23

Even Dry Eye Specialists Get the Blues. 11/26/23

Revisiting Thyroid Eye Disease (TED). 11/19/23

Testing Part 8. 11/12/23

What Do Dry Eye Tests Mean? 11/06/23

What Do Dry Eye Tests Mean Part 6. 10/29/23

What Do Dry Eye Tests Mean Part 5 10/22/23

More on Staining the Surface of a Dry Eye and What It Means Part 4. 10/15/23

What Do Dry Eye Tests Mean Part 3. 10/08/23

What Do Dry Eye Tests Mean Part 2. 10/01/23

What Do Dry Eye Tests Mean? 09/24/23

Is It Safe to Buy an Eye Drop? 09/17/23

Can (CCH) Conjunctivochalasis (or anything to do with poor health) get better without surgery? 09/10/23

More Infectious Eye Drops and an FDA Warning. 08/27/23

How Early in Life Can We Get Dry Eye Disease? 08/20/23

Castor Oil Shouldn't Be Rubbed in the Eyes. 08/13/23

Introduction To Dry Eye Disease. 12/29/21 to Present 

Prior Index to Dry Eye Posts 7/23/23 https://www.eyethera.com/blog/index-of-blog-posts?rq=index

Dr. Edward Jaccoma, MD 10/21/24 Dr. Edward Jaccoma, MD 10/21/24

Winter is coming! How this can require extra “adjustments” when you have dry eye disease.

Apart from the Internet streaming services we default to and may binge on (like the HBO GOT series this title riffs on), many of us (at least in the Northern Latitudes) will spend even more time inside, staring at screens and/or books to pass the winter months - and dry eye patients often ask what they can do to mitigate their misery during this season.

A close colleague of mine (who I just met in person after collaborating for years) Dr. Laura Periman recently posted to a FB group of dry eye sufferers, this golden nugget: “Cold air doesn’t hold as much water as warm air. Radiant heat instead of forced air heat may help. Also, Ziena (moisture chamber) glasses or onion goggles.” To further riff off this information, an obvious but often overlooked addition, is to add a humidifier to moisten the air and avoid sitting near sources of moving air (like fans).

I also posted to the same question, “in my experience, the amount of attention and reflected light from the average digital screen can be more detrimental to blinking and evaporation than a printed book with "adequate" lighting (super bright lighting can also reflect strongly off a printed page and will depend on the quality of the paper as to how "reflective' it is). There are screen lighting options that can reduce the digital glare, as well as some glass coatings for your glasses.”

Such eyeglass coatings can include:

Anti-reflective coating – this is particularly helpful as this can reduce glare (so sometimes referred to as “anti-glare”) by reflecting unnecessary light rays that would otherwise be further scattered by a dry eye’s surface, making it harder to see clearly. Since light accelerates evaporation (I use the analogy of rain clouds dropping their water on the ground. If the clouds shield that ground moisture from the sun, the ground stays wet – but part the clouds and shine the sun and the water rapidly disappears (evaporates).
Anti-fog coating – when coming in from the cold, dry air, glasses will tend to fog up inside a warmer, moister area like your well-humidified home, store or office. Anti-fog coatings can come in many forms including those you can apply from towelettes or via sprays.
Blue light filtering coating – I covered this in some depth in an earlier blog post, here: https://www.eyethera.com/blog/do-blue-blocking-glasses-help-with-dry-eyes?rq=blue%20light
UV protective coating – UV comes in 3 forms, UVA, UVB and UVC. Unless you are a welder, you probably don’t need to worry about UVC (the most damaging of UV light) as it is fully absorbed by the Ozone layer in our atmosphere. But UVA and UVB are not sufficiently impeded by the Ozone layer and can be detrimental to our eyes (and skin). Wearing UV coating protection can be helpful to our eyes (and wearing sun blocking agents helpful to our skin).
Scratch-resistant coating – If, like me, you can be “hard on glasses” then such coatings over plastic lenses can save the cost of more frequent replacement (or wearing scratched up glasses that can blur our vision and add to unnecessary eye strain).

Use of contact lenses can also be more challenging since a decent tear layer is most often needed for a proper fit and good tolerance of wearing them. I covered more about contact lenses – and their care, here: https://www.eyethera.com/blog/z9r2sgjxe1iyza1k6535laildtqilm?rq=contact%20lens and here: https://www.eyethera.com/blog/6g9blza7q7q9zmhychmq509nsad9a4 - so if you are nearsighted enough to read comfortably without your glasses or contacts – or can wear reading glasses instead of contact lenses, then that may be a better option (at least in dry, winter weather).

As always, I recommend consulting a good dry eye expert/specialist to help determine what is best for you and your eyes.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.

Dr. Edward Jaccoma, MD 10/13/24 Dr. Edward Jaccoma, MD 10/13/24

A New Energy option - Plasma Pens and Dry Eye Disease!

What is Jett Plasma therapy, and would it help dry eyes?

Jett Plasma Medical (or JPM) is a direct current-mediated medical device that uses the “4th state of matter” to provide highly targeted treatment of skin and mucous membranes. Developed in Europe and now used by some practices around the world, I am excited to announce being chosen as the first practitioner in the USA to acquire this novel device. While I’ve had it “under my wing” since May of 2024, it has taken approximately 5 months for me to feel comfortable with the device and its uses as they apply to a number of my dry eye patients. Currently, treating dry eye disease is recognized as an “off label” use as it has not been evaluated for this purpose by the FDA yet in this country.

Plasma is recognized as the 4th state of matter, since there are solids, liquids, gases and then plasma. Using Radio Frequency energy, it is possible to create a plasma (in simple terms, an electrically charged ion cloud) from the gases in our atmosphere. These “ion clouds” contain electrons, which can flow into and out of the ion cloud, with predictable precision. I should note that there have been many machines marketed as plasma energy devices in the USA, which have been available for some years (and largely used in the aesthetic side of medicine). Combining certain gases and alternating currents can provide much higher levels of plasma energy, but in my research, the Jett Plasma Pen with its direct current technology is uniquely suited to treatment around delicate eye and eyelid areas with its unidirectional energy flow.

In several of my posts, I’ve detailed how “ion channels” are gateways into and out of cells responsible for making tears (among every other cellular function in our bodies). Electrons from the plasma can spin off and create more of these ion channels in an event called “electroporation.” These tiny “pores” are then gateways allowing passage of the ion “tokens” to activate various cellular functions. In low power delivery, this can have the ability to “recharge” the cells, reinvigorating them. Laboratories have used this technology for years to alter the states of cell cultures to tweak them into revealing cellular secrets and to change them in ways that can benefit humanity. When the power is intensified, it can reliably take out weak and dead cells or be used in a more surgical way to penetrate, cut, cauterize and behave like a precision scalpel. Medications like steroids may be in a better position to enter tissues when applied during a treatment. Activating the mucin-producing goblet cells, plasma helps them deliver their mucous during a treatment!

Add to the repertoire of this plasma energy, the electrical stimulation of muscles and nerves. Electricity is the common activator throughout our bodies and this plasma application can equally stimulate them. Patients report a feeling like a “TENS” unit (an electrical device used to stimulate nerves and muscles to reduce pain). This can also create a “tingling” sensation around dental fillings and metal implants. Like other RF devices, we don’t apply this energy to patients with pacemakers or other implanted electrical devices that cannot be safely turned off during a treatment. A benefit of activating muscles in the lid is that this can facilitate the emptying of the Meibomian Glands – as well as encouraging and strengthening those muscles. In a common aesthetic application, this muscle strengthening adds some natural “filling” of the tissues, which can add “air into the balloon” that is our face. Stimulating the skin, while strengthening (and “bulking up”) the underlying muscles - can result in smoother, younger-looking skin and facial features.

In my clinical practice, this has augmented the abilities I have to treat my dry eye patients. Specifically, some lid margins develop “capping” over the openings to the oil producing Meibomian Glands, and this technology has helped me to sequentially “scour” this capped material (waxes, skin cells, keratin, bacteria and the like). By removing this biologic “varnish” from the surface, it allows freer access to these oil glands and their oily products (meibum). Secondly, by applying this energy over the conjunctival membrane overlying these glands, I’ve witnessed the plasma’s capacity to breakdown and breakup the heavier “concrete-like” products inside those that have more advanced clogging of this type. My tools have so far been limited to using mechanical cleaning and scrubbing devices (ZEST and BlephEx), heat (RF, Lipiflow and the like), light (IPL) and probes (of Dr. Maskin’s design). I’ve had to “scrape” the lid margins to reduce the “varnish” and apply substantial pressure to move some of these “concrete-like” products from the glands.

In a series of prior posts, I detailed the apparent source of the more “pasty” meibum as coming from the interaction of germs with the normal human oils within these glands. These “germs” can include the decaying bodies of Demodex (the tiny mites that frequent our lids – more of my posts deal with that ugly issue) – who may feed on even smaller bacteria (as well as dead skin cells and our oils). In researching Dr. Maskin’s work (and others), scar tissue can also contribute to clogging, as well as the tiny “keratin granules” that can also form in our oil glands. Keratin is the stuff of hair and nails, so it is no surprise that such material can also be a significant source of an oil gland’s clogging. Remarkably, the plasma appears to break this all down into a more liquid form and allows me the clinical ability to move this stuff out of these highly clogged glands when nothing else appears to do the trick.

So, is Plasma the “Holy Grail” of dry eye (and perhaps all of medicine)? I wish it was that simple. I find that each of my tools has their own clinical (and often unique) usefulness. Much as the Plasma can be used to kill germs and “clean” lids, I still find a ZEST-modified BlephEx to be a quicker, simpler and in some cases, likely more efficacious tool for general lid cleaning. In some cases, I would recommend using that as a “starting tool” and then add the Plasma treatment on top of that, since it can then sequentially scour more persistent “varnish-like” capping material when needed. Plasma (in this iteration) doesn’t significantly raise the temperature of the tissue the way we can with other modalities (like my off-label use of the many Radio Frequency tools available today). Once oils turn to wax, any reliable heating device can offer a general purging of the waxy oils in a quick, noninvasive, in-office procedure. IPL, while poor at heating clogging waxy oils, is great at closing off abnormal, inflammation-carrying blood vessels – something that appears unique to this light therapy. IPL and some Low Level Light Therapies, also have been heralded for uniquely activating the cells that make tears (a term called “photo-biomodulation”). This appears to activate the cellular furnaces (called mitochondria) which can add energy to the cellular function. Plasma can also affect cells in a “electro-ionic-biomodulatory” way, thanks to the ion channel effects – so I would postulate that the two forms of therapy may be “synergistic,” where each can augment cell functions in their own unique and additive way.

Where RF and Plasma overlap, is in their abilities to perform delicate surgical tasks. Plasma Pens have been recognized for plicating conjunctivochalasis – abbreviated CCH (typically with tiny “spot weld-like” cauterization points). Each point will heal with tiny scars, binding the “CCH” or loose membrane, back to the white (sclera) of the eye wall. Another overlap is in the ability to turn wayward lids in the direction that better suites normal lid function (see my posts on the eyelid innie and outtie). Some doctors in Europe have been using Plasma for a less invasive form of blepharoplasty (again using the small point-like cautery function to tighten the skin without actually cutting it). Having a new tool is exciting and exploring the range of what it can do is still a work in progress – made easier and safer thanks to colleagues in Canada (Drs. Friedman and Salsberg in Toronto), as well as many in the EU and the COMPEX team that developed and are now marketing this tool in the Czech Republic). For more information, see this link: https://www.ophthalmologytimes.com/view/nonablative-treatment-offers-safety-efficacy-and-multiple-applications-for-the-cornea

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.

Dr. Edward Jaccoma, MD 10/6/24 Dr. Edward Jaccoma, MD 10/6/24

More Dry Eye News (& how do I know if I have dry eye disease?)

While I’ve covered some of this before, I had a dry eye sufferer recently ask me if they had MGD - knowing that they had Conjunctivochalasis (CCH) from another doctor. My answer was like this:

“While testing with fancy equipment is helpful, most doctors can tell by observing how quickly the tears evaporate during their slit lamp exam and then by pressing over the oil glands during the same exam. One less specific but generally helpful way for you to test at home, is to set a stopwatch for 20 seconds and then blink. Start the watch at the moment of your blink and time how your eyes feel over those 20 seconds without blinking. If you comfortably can last the full 20 seconds and your vision doesn’t change, then there’s less chance you have MGD. (My very first post touched on this test here: https://www.eyethera.com/blog/rn9p8ouyjzjhyfpkvrysxjx28no0q8?rq=blink%20test ) In my experience, most people with CCH also have MGD, but every case is different.”

Recently a new “dry eye hack” has come on the study scene that can help address this rapid evaporation - a so called “TRPM8 agonist” that is being studied as an eyelid wipe that can trigger the “Sprinkler System” to create a fuller tear production. “Transient receptor potential melastatin 8” or TRPM8 to those in the know, opens the “ion channels” I described in my posting about how tears are made (I describe ions as “tokens that open gates” in this blog: https://www.eyethera.com/blog/making-tears-part-2?rq=ion where the gates are the so called ion channels). Key to this discussion is how various ions that pass through certain gates can trigger tear production at higher rates. TRPM8 is the gate triggered by the cooling common to evaporation - so a NORMAL response to evaporation, is to make more tears. Since eyes with MGD have accelerated evaporation (because the lack of oil exposes the water of a tear to air - which leads to early and extensive evaporation), one of the common complaints I hear from my MGD patients, is how their eyes “puddle up” when they expose their eyes to cold, dry air.

In a normal eye (without dry eye disease), the healthy tear produced by evaporation would have enough oil floating on top, so as to “seal in” the moisture under that oil and allow a healthy patient the opportunity (should they be so inclined) to continue skiing down the slopes without leaving a trail of salty tears in their wake. Adding a chemical to the lid’s margins - that causes the ion channels to trigger tearing - would create the same effect that the skier encounters (without the skies and without the cold dry air of the slopes). I think this could be a good adjunctive treatment for dry eye patients, but that it would work best if that tear can contain enough “good oil” to act as the natural “shield” that protects this tear from rapid evaporation. Otherwise it seems likely it will spool up the “Reflex Tearing” of the “Firehose.” This means more salty tears that will also rapidly evaporate and potentially leave a patient looking like they are actively crying (when they don’t mean to).

I discussed “Neurostimulation” in an earlier post https://www.eyethera.com/blog/what-is-neurostimulation-for-dry-eye-treatment-and-do-i-need-it?rq=fire%20hose and see the TRPM8 stimulators as a somewhat related version of this. If the oil glands are overly “clogged” then any stimulation of the tear production is liable to produce salty tears that will go on to evaporate and leave more salts behind. Another of my posts goes into more detail about why you don’t want “overly salty tears” here: https://www.eyethera.com/blog/overly-salty-tears?rq=fire%20hose Ultimately, it is crucial to protect, support and encourage your oil glands to do their best. If they work well, then many of the other technologies to stimulate good tear production will help you make good tears!

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.

Dr. Edward Jaccoma, MD 9/29/24 Dr. Edward Jaccoma, MD 9/29/24

More on unapproved and possibly dangerous eye drops.

FDA warns consumers of contaminated copycat eye drops

https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-contaminated-copycat-eye-drops?fbclid=IwAR085_VOsxm-9x0CtykAzUJF2Fb4Rn2nQzBFAd7HYsdwc6EBKu31z9hy_jI_aem_AfyHpReFyoRIaWRypfQKaucUi2WHDOhHkA7HxmLNfxqe1dwwFHXGJmlWgjMWkFb2a-A

“The (US)FDA is warning consumers not to purchase or use South Moon, Rebright or FivFivGo eye drops because of the potential risk of eye infection.

These are copycat eye drop products that consumers can easily mistake for Bausch + Lomb’s Lumify brand eye drops, an over-the-counter product approved for redness relief.”
While most of you know my stance on the “eye whitening” eye drops like Lumify (as well as some Visine, Clear Eyes and others advertising to “get the red out”) -

I posted on this topic here: https://www.eyethera.com/blog/can-i-use-eye-whiteners-like-visine-or-lumify-when-my-eyes-get-red?rq=lumify

They go on to say “South Moon, Rebright and FivFivGo eye drops are unapproved drugs and should not be available for sale in the U.S. They claim to treat eye conditions such as glaucoma, which is treated with prescription drugs or surgery.

Patients who have signs or symptoms of an eye infection should talk to their health care provider or seek medical care immediately. FDA recommends consumers properly discard these products.”

Of particular concern, is how close the packaging was made to copy the Bausch and Lomb Lumify product:

“Comparison of authentic Lumify with copycat products

The South Moon, Rebright and FivFivGo photos are examples of the images that appear on various websites. Some of these copycat products may be falsely labeled with “Bausch + Lomb” at the top of the packaging. The actual products may look different.”

Of potentially equal or greater concern (with Halloween around the corner) is this statement by the American Academy of Ophthalmology (AAO): “What Ophthalmologists Want You to Know About Eye Color-Changing Drops

What NOT to do for Halloween (or any other time of the year)!

“The American Academy of Ophthalmology says popular products making the rounds on social media are unproven, unregulated, and potentially dangerous

SAN FRANCISCO, Calif. — The American Academy of Ophthalmology is sounding the alarm on over-the-counter eye drops advertised as eye color-changing solutions. These products are not FDA approved, have not been tested for safety or efficacy, and could potentially damage the eyes.

“Consumers seeing these products on TikTok or elsewhere online need to know that they are not FDA approved,” said JoAnn A. Giaconi, MD, clinical spokesperson for the American Academy of Ophthalmology. “The ads show dramatic before-and-after shots and vague information on how the drops actually work to change eye color. But here’s the reality, there’s no evidence that they do anything at all, and no evidence that they’re safe.”

Because the products are not FDA approved, they have not undergone rigorous safety and efficacy testing, and it’s unclear if Current Good Manufacturing Practice regulations were followed during production. Unregulated manufacturing facility conditions can lead to contaminated products that can cause dangerous eye infections.

Potential safety risks of using unregulated eye drops include:

Inflammation
Infection
Light sensitivity
Increased eye pressure or glaucoma
Permanent vision loss

Manufacturers claim that the drops include an ingredient that adjusts natural levels of melanin in the iris, the colored part of the eye. But there is no evidence that the formula can target the iris pigment. And if the drops did destroy the pigmented cells in the iris, it could potentially harm the eye, causing light sensitivity, eye inflammation, and eventually vision loss. It’s also unclear how other parts of the eye that rely on melanin to function properly, such as the retina, would react to this ingredient.

“Social media and the internet are full of potentially dangerous eye health claims. Bottomline, the Academy advises the public to never put anything in the eye that isn’t made to go in the eye,” Dr. Giaconi said. “You’re putting yourself at risk for painful eye conditions or even blindness.”

The safest way to change eye color is with colored contact lenses, but only if the lenses are prescribed, dispensed, and fitted by a qualified eye health professional.

For more information about eye health and how to protect your eyes, visit the Academy’s EyeSmart website.”

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Also note that past topics I’ve posted on can be easily found by using the “Search Bar” in the blue gauze “mask” on the woman at the top of the Blog Page.

Dr. Edward Jaccoma, MD 9/22/24 Dr. Edward Jaccoma, MD 9/22/24

A patient’s plea for help - and what YOU can do to help them…

If you’re reading my posts, then chances are better than even that you have some degree of dry eye disease, in which case, then you, like many of my patients, will question if treatments can return you to a state of “normalcy.”

The short answer is yes - because I also have dry eye disease with Rosacea and primary Meibomian Gland Dysfunction and have been able to function well for the last 12 years knowing that I have this problem and treating it accordingly. I’ve offered treatments for nearly 40 years of my dry eye care practice but have been practicing this degree of interventional dry eye care for only 12 years at this level - and find a range of patient problems that require a range of treatments to fix these problems, as well as a range of improvement, depending on the patient, the range of the problem, and the degree of treatment.

I have an ask for you - that you find the FaceBook online Dry Eye Support Group (assuming you use FB/Meta) and then post there - if you feel that treatments have allowed you to return to a state of “normalcy” (where you might sometimes forget to do some of your dry eye “homework” because you feel good enough that your eyes are again being taken “for granted”). These dry eye sufferers generally have yet to feel that “normal” and are still looking for validation that some of these therapies can actually work for them.

Generally speaking, the earlier you catch the disease and the more aggressively it’s treated, the easier it is to turn it around,. Caught and treated early, it becomes easier to achieve a degree of normalcy. Maintaining this normalcy, in my experience, often requires a fairly structured program of “homework“. For most, this consists of getting enough oral omega 3, 6 and 9 oils (and digesting them), as well as regular strong, blinking patterns with occasional hot compresses for those with the waxy obstructive version of this problem (or Meibomian Gland Probing, for those with the tougher, scar tissue obstructions). It is also critical to address inflammation through diet and lifestyle as well as sometimes requiring medication as well as sometimes IPL or other therapies. Lid Hygiene is always important and I look at this a bit like I look at the dental issues that we suffer. Those who take care of their lids will have better function and longer lasting glands.

Many ask about the regular use of artificial tears when they are suffering with dryness. Eyes need moisture and using artificial tears when you can’t make your own is a good thing to do. However, I’ll differ with the American Academy of Ophthalmology (who recommend use of preserved artificial tears up to every 2 hours), in that I only recommend preservative free artificial tears if you’re going to use them at all. This is because any preservative is a toxin and applying toxins to your eye on a regular basis is only going to contribute to more problems making tears - as you hurt these tiny glands trying to make your tears, with those toxins. The biggest concern that I have is, if your only treatment is artificial tears, then you are applying a Band-Aid to a deeper problem that in essence “Kicks the can down the road” without solving the problem that’s causing the problem. I’ve posted on this before, here: https://www.eyethera.com/blog/why-cant-i-just-use-some-tear-drops-or-ointments-instead-of-all-this-work?rq=artificial%20tears

I advise that you should seek the advice of a good dry eye doctor who can best diagnose what’s causing your problem and help you to fix it. Working with the good dry specialist is your best recourse!

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 9/15/24 Dr. Edward Jaccoma, MD 9/15/24

Study looks at the correlation of humidity, temperature, and air pollutants on dry eye disease patients

https://www.ophthalmologytimes.com/view/study-looks-at-the-correlation-of-humidity-temperature-and-air-pollutants-on-dry-eye-disease-patients

While this study only included 53 patients, they did find statistical significance in common parameters associated with air pollution. No great surprise that polluted air will aggravate dry eye disease!! But it does elevate concern that we need to take steps to ensure we live in clear, clean air. Our eyes are covered in our body’s living cells - and as such, this delicate, important, advance-life-form is truly the “canary in the mine.” For those unfamiliar with this analogy, coal miners digging many hundreds of feet below the surface of the earth, could encounter pockets of toxic or flammable gases that could be odorless to human noses. Miners would carry canaries with them, as these delicate birds would succumb to these gases before they would otherwise be toxic to a human. When the canary looked sick (or went belly up), then the miners knew it was time to get out of the mine. As a physician, scientist and fellow human with kids and grandkids to worry about, I hope we can control the human footprint we are pressing into the backbone of our world before we succumb to the toxins we are fast-creating.

Dr. Edward Jaccoma, MD 9/8/24 Dr. Edward Jaccoma, MD 9/8/24

Rosacea takeaway “Pearls”

After 10 posts on Rosacea, it occured to me (after a much needed summer vacation), that I could wrap this up with some general suggestions I often share with my Rosacea patients. While much of this mirrors my take on dry eye treatments in general, I do have more specific, Rosacea-related “Pearls” I can share.

If the Meibomian Glands (MGs) are clogged with waxy oils, it remains critical to clear them. A “heated massage” from a dry eye specialist using appropriate equipment is often necessary - and there are many effective options for this, depending on the “melting point” of the clogging. Milder clogs (of a buttery consistency) will usually respond to most modalities and can sometimes be cleared through “homework” using a heat mask (like a Bruder) and “lid crunches.” I coax patients to apply the heated Bruder mask for 3-4 minutes, while meditating or listening to a favorite song (most last this long). After the 3-4 minutes of continuous moist heat, the more buttery secretions can become more liquid - but as soon as the heat is removed, the oils will firm back up. Using the retained heat, while leaving the mask in place, a conscious, firm (but not grimacing) upper and lower eyelid “squeeze” will compress the glands and squeeze out the liquid oils. Counting to 3 to compress and then to 3, to relax the lids, we repeat this exercise about 20 times (which takes about 1 minute). At the conclusion, you remove the mask and hope to sense looking through a “greasy tear",” which is slightly blurry, but an accomplishment in terms of turing over the thick, old oils - and making room for newer, fresher oils.If the nature of the patient is to produce thicker oils, then a routine use of this heated expression several times a week can result in consistent, better flow. It also helps strengthen the lid muscles (so even unconscious blinking can become stronger blinking) and it may help intensify “muscle memory” - so that those unconscious blinks become actively stronger blinks throughout the day.
If MGs are able to produce thin, clear oil on exam, then a heated expression is less helpful and can become counter productive. This is because the greatest purpose of heat is to thin oil and dilate the pores that are the mouth of these glands. But if the oil can flow easily, then heat is not only unnecessary, it can dilate the blood vessels distributing the proteins and chemicals that produce inflammation - thereby increasing redness, swelling and damage to tear-producing cells. When clogged MGs are unclogged through treatments, this is usually a fair tradeoff against the inflammation from dilating blood vessels - as poor or absent oils will aide evaporation and increase inflammation. I liken these thin, clear, but inflammatory oils produced by rosacea-affected MGs as being more like “kerosene” than being the better “extra-virgin vegetable (& fish) oils” our eyes would prefer. When I treat eye patients with Rosacea, I will commonly use a deep eyelid-cleaning tool (BlephEx and/or ZEST), IPL and a heated expression (with off-label Radio Frequency). Following the heat of IPL with a little more heat and massage will help unclog any waxy oils, but also can help “purge” any inflammatory oils - making way for better, newer oils to be produced.
Once Rosacea-related oils are flowing, the trick is to keep them flowing and containing the “good oils” rather than the “bad oils.” This usually comes down to consuming and digesting enough quality Omega oils 3, 6 and 9 to nourish the MGs, as well as promoting the production of oil from these MGs, with strong regular blinking throughout the day. Lastly, providing adequate eyelid hygiene, to prevent germs from subsisting on these oils in quantities that can turn these oils into soapy, chunky residues. Those with poor oil absorption issues (absent or reduced gallbladder function, inflammatory gut problems, etc) may need help varying from adding Lipase supplements to adding anti-inflammatory medications and taking lower frequent doses in a schedule of oil intake that is compatible with the degree of absorption available.
To reduce inflammation getting into the oils, taking oral antibiotics like Doxycycline or Azithromycin can often be helpful (but not until the oils are mobile). An adjunct to - or even a replacement for - the antibiotics, can be IPL, and I recommend my patients seek out dry eye specialists who can provide IPL treatments when appropriate (not all skin types are IPL appropriate and there are certain exclusions to IPL therapy. A dry eye specialist who can offer IPL is usually well versed in all this).
Anti-inflammatory diets can be another useful adjunct, as can a lifestyle where sun protection, adequate exercise, limits on caffeine and alcohol, spicy foods and other “rosacea triggers” are observed. Meditation, yoga and other stress relieving activities can also have positive benefits.
Catching Rosacea early and dealing with it effectively is most helpful, as once Rosacea is well entrenched, the larger, active blood vessels that produce the “rosy” appearance become harder to shut down. Careful examination - and treatment - of Demodex, may mean additional hygiene steps, but can really pay off. Since Rosacea is a genetically “programmed” tendency towards inflammation, the treatments are usually required in differing amounts and degrees, for a lifetime. Prescriptive topical and oral medications, IPL and other office-based treatments are often required as “maintenance” that vary with the degrees of Rosacea-related disease. Such interventions are sometimes only needed yearly - but sometimes multiple pulses of therapy are required many times a year, and the intervals can vary over time according to genetics, age, environment, adherence to “homework” and by the skill and technologies employed by the treating doctor.
If the Rosacea is limited to the eyes (Ocular Rosacea), it can generally be handled by an experienced eye doctor, but if it affects broader areas of the face and body, then it is often necessary to work with a team that would include the Dermatologist, and may include Gastroenterology, Rheumatology and Neurology. Since we as a rule are living longer and using our eyes more than prior generations, taking good care of our eyes becomes even more critical - and Rosacea is a common problem with good treatment options that help ensure that our eyes can last (comfortably and usefully) for as long as we do.

Because I’ve posted extensively on details of my recommended Omega oil supplements, lid hygiene, treatments for Demodex, etc, I will steer those interested into reading my posts from the beginning - or you can use the “search” bar (in the blue “gauze” under the leading lady’s eyes) to hopefully find what you’re looking for.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 8/4/24 Dr. Edward Jaccoma, MD 8/4/24

Rosacea and Dry Eyes Part 10: more on treatments (& Demodex)…

The following consists of a report on the off-label use of a common treatment for rosacea that can be applied to the lids and lash area as described from the article below. It was the basis for much of my treatment before Xdemvy became commercially available (just one year ago this month) and can be found in my earlier post, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease

Treatment of ocular Demodex infestation with topical ivermectin cream

“Ivermectin 1% cream was approved by the FDA in 2014 for the treatment of rosacea, a Demodex-associated condition.32 The cream was found to be well tolerated in FDA studies, leading to skin irritation and a burning sensation in less than 1% of patients when used during a 12-week study period.33, 34 Topical ivermectin 1% cream has been reported to be effective in treating ocular rosacea,35,36 and was recently found by Choi et al. to be effective in treating Demodex blepharitis.37 In their study, ivermectin 1% cream was applied weekly. However, the findings of this case series suggests that even a single application of ivermectin 1% cream has a very potent and prolonged effect that lasts for several months, making weekly application unnecessary.

The patients in this series reported that the cream caused temporary ocular stinging and burning, which was mitigated by instillation of a topical anesthetic. The symptoms did not recur after the anesthetic wore off. Temporary blurred vision was also reported, but no one felt unsafe to drive after 30 minutes. An increase in dry eye symptoms commonly occurred a few days after treatment.

In summary, this case series presents compelling anecdotal evidence of the effectiveness of a single or double application of topical ivermectin 1% cream in producing a prolonged, months-long reduction in the clinical signs of Demodex infestation. Further investigation of the off-label use of topical ivermectin 1% cream for ocular demodicosis is warranted to confirm its efficacy and to develop protocols that extend the duration of treatment effect.

The treatment consisted of instilling a drop of proparacaine into each eye. The exam chair was reclined. A dry cotton-tipped applicator was used to evert the lashes. Another cotton-tipped applicator with ivermectin 1% cream (Soolantra, Galderma, Ft. Worth, Texas, USA) was used to apply the cream to the base of the eyelashes, taking care to keep the cream off of the ocular surface (Fig. 1). After ensuring that the eyelash bases of both the upper and lower eyelids were saturated with the cream, it was applied to the surrounding upper and lower eyelid skin. The cream was left in place for 10 min, after which a sterile saline-soaked eye pad was used to remove the excess cream from the eyelids. Dry cotton-tipped applicators were used at the slit lamp to remove excess cream, and the remainder of the cream around the lashes was left in place. Artificial tears were instilled if the patient was experiencing ocular burning or irritation.”

My “take home” message about Demodex and Rosacea, from my personal experiences and this post, is that Demodex is a common irritant that will aggravate rosacea and its related inflammation - both on the face and on the lids (which can spill over as inflammation onto the eyes). Ivermectin 1% cream and the newer eye drop, Xdemvy, have proven of value in reducing the load of Demodex and the related inflammation. Since inflammation is a foundational aspect of dry eye and related ocular surface diseases, it is often important to address this common mite. Protocols continue to evolve around “best practices” and may require customization according to the degree of its effect on the individual patient.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 7/21/24 Dr. Edward Jaccoma, MD 7/21/24

Rosacea and Dry Eyes Part 9

As this is a focus on dry eye disease, it is necessary to include more on the Treatment of Ocular Rosacea- (with another nod to the J. Hopkins Review Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003 ) *(I’ve put my comments in parenthesis with a leading asterisk to help annotate the actual published reporting. The bold faced type is my emphasis and not from the published articles).

Patients with mild ocular rosacea often present with a dry gritty feeling in the eyes; they can usually be treated by lid hygiene and lubricating eye drops. Patients with more severe ocular rosacea present with burning or stinging of the eyes, crusting of the lid margins, or formation of chalazia and hordeola. They frequently need topical or systemic antibiotics, or cyclosporine.
Topical cyclosporine 0.05% ophthalmic emulsion *(Restasis, with now a variety of compounded and more generic formulations available) has been shown to be more beneficial than artificial tears in the treatment of ocular rosacea (low quality evidence).76,100 For the more severe ocular rosacea, referral to an ophthalmologist is prudent.

Physical Treatment of Rosacea - above referenced J. Hopkins Article

• Telangiectasia *(I discussed these fine, red, “spider lines” caused by dilated superficial blood vessels in the lead blog of this series, with photos that demonstrate them).

Reduction in telangiectasia is not to be expected with any of the currently available topical agents for rosacea. However, these features frequently become a psychological burden and can substantially impact rosacea patients' quality of life.
Destruction of dilated vessels by vascular lasers or intense pulse light is the primary therapy to reduce telangiectasia. Light energy is absorbed by hemoglobin in cutaneous vessels, leading to vessel heating and coagulation.
Most commonly used for the treatment of erythema and telangiectasia in rosacea patients are the pulsed dye laser (PDL, pulsed dye laser, 585–595 nm) and intense pulse light (IPL) devices.101,102
-

According to the latest Cochrane Systematic Review, pulsed dye

laser and intense pulsed light therapy were each associated with erythema and

telangiectasia improvement, but without difference between treatments (moderate

quality evidence).76

________________________________________________________________________________________

Drawing from published data and discussions in Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ko HS, Suh YJ, Byun JW, Choi GS, Shin J. Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ann Dermatol. 2017 Oct;29(5):543-547. doi: 10.5021/ad.2017.29.5.543. Epub 2017 Aug 25. PMID: 28966509; PMCID: PMC5597646.

The recurrence rate of rosacea was not known very well, but has been reported as 60% in 6 months after withdrawal of the drug *(minocycline - which is a tetracycline-derivative similar to doxycycline). It is not known which treatment can reduce relapses of rosacea effectively.
The objective *(of this study) was to identify whether 595 nm-pulsed dye laser (PDL) treatment reduced recurrence rate among rosacea patients who were treated with oral minocycline.

One hundred and seven Korean patients with rosacea who started treatment with oral minocycline (100 mg/d) with or without PDL (2∼4 sessions) were evaluated retrospectively.

Cox proportional hazards model showed that the combined use of PDL with oral minocycline appeared to be a significant protective factor for the hazard of recurrence of rosacea (hazard ratio, 0.492; 95% CI, 0.257∼0.941; p=0.032).
Patients were categorized into 2 groups according to the treatment modality:
– Group 1: Oral minocycline (100 mg per day) alone
– Group 2: Oral minocycline (100 mg per day) plus 595 nm-PDL (total 2∼4 sessions)

The PDL (Pulsed Dye Laser) (595 nm, VBeam; Candela/Syneron, Wayland, MA, USA) settings were: fluence, 10.0 J/cm2; spot size, 7 mm; pulse duration, 10 milliseconds; and passes, 2 with 10% overlap of treatment spots. The settings were standard subpurpuragenic settings, including published guidelines and company-recommended ones at the time of the study7. *(Important to note from the above quoted, earlier J. Hopkins report, that PDL was found equal to IPL - or Intense Pulsed Light. As a provider who owned and operated a VBeam PDL prior to switching to a Lumenis M22 IPL system, my general sense is that IPL is likely safer over and around eyelids - but is also similar in results to PDL at the common treatment levels for rosacea. It is worth another look at my earlier post on IPL here https://www.eyethera.com/blog/do-results-of-ipl-treatment-vary-by-technique-and-by-the-filters-used-amp-does-it-regenerate-withered-glands ).

Pulsed dye laser (PDL) has been suggested to be used adjunctively with oral and topical rosacea regimens for more complete symptom resolution6. PDL shows a therapeutic effect by photo-thermolysis targeting oxyhemoglobins within cutaneous vasculature7,8. PDL is effective for erythema, flushing, telangiectasia and even inflammatory lesions in patients with rosacea6,7,8. Biopsy specimens which were taken from patients with rosacea 3 months after PDL therapy showed that nerve fiber density and number of substance P immunoreactive nerve fibers were decreased9,10. However, exact relationship between this and the therapeutic effect of PDL has not been demonstrated yet.

The multiple Cox proportional hazards model showed that PDL treatment added to oral minocycline was an important protective factor for a hazard of the recurrence of rosacea (HR, 0.492; 95% CI,
0.257∼0.941; p=0.032). The treatment duration with oral minocycline was not a significant prognostic factor for the recurrence of rosacea (p>0.05).

This study showed that the 1 month-recurrence rate after oral minocycline alone was 17.2% and the 6 month- recurrence rate was 66.8%, which is similar to the results of previous report.

In the present study, the 1 month-recurrence rate was 3.2% and the 6 month-recurrence rate was 49.2% after PDL in combination with oral minocycline therapy.

Generally, two to four laser treatments are required to achieve best outcomes for rosacea6. Patients with total 2∼4 sessions of PDL were only included in this study. When we evaluated data including patients with a single session of PDL, the recurrence rates between groups were not significantly different (data not shown). It means a single laser session is not enough to see the therapeutic effect.

_______________________________________________________________________________________

*(My personal take on this mirrors my clinical observations. 4 IPL treatment sessions are generally required for optimal control of rosacea. Adding Doxycycline - or any Tetracycline-derived oral antibiotic such as Minocycline - can enhance the treatment value. This appears to lead to a higher level of improvement in some cases, but to a more lasting benefit in most cases. It also speaks to my general recommendation for “maintenance” IPL treatments every 6-12 months regardless of whether a tetracycline is used adjunctively - and some may benefit from even more. I’ll cover a little more on Rosacea treatments in the next blog posting!)

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 7/7/24 Dr. Edward Jaccoma, MD 7/7/24

Rosacea and Dry Eyes Part 8

Treatment continues to point back to the immune system, starting at a genetic level and then to the gut…

Woo YR, Han YJ, Kim HS, Cho SH, Lee JD. Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis. Int J Mol Sci. 2020 Nov 10;21(22):8427. doi: 10.3390/ijms21228427. PMID: 33182618; PMCID: PMC7696644.

Treatment of Rosacea- Johns Hopkins Review Article

Historically, rosacea was treated by bloodlettings and application of leeches on rosacea-affected skin.67 Rosacea therapy has changed since then, but a curative treatment approach has not yet been developed. Thomas Bateman's quote holds true to date: “The perfect cure of [acne] rosacea is, in fact, never
accomplished” (from Delineations of cutaneous diseases, 1812).
Most current guidelines are based on the identification of the rosacea subtype to select the appropriate therapy. However, in reality there is often an overlap of clinical features across rosacea subtypes in each patient, requiring several therapeutic strategies for optimal outcome. Thus, there is no single best way to treat all rosacea patients.68-70
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003

I think it is clear that until we can manipulate the genes responsible for Rosacea and reorganize the gut flora around an individual’s immune system, that Mr. Bateman’s quote is likely to remain true. Fortunately, there have been many headways made into the treatment of Rosacea since 1812!

**I believe this review article applies well to the ocular rosacea I see in my practice - particularly in regards to the “life-long treatment intervention.”** For most, this is pretty simple - but for some, it can get quite complex. The simplest can be practicing ample lid hygiene, including control of the stubborn mites called Demodex. (see my earlier posts on these topics, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease and https://www.eyethera.com/blog/why-do-some-people-produce-pasty-meibum-part-4 (among others in earlier posts). Continuing in our review of this article, I’ve pulled some general recommendations as follows, below:

Treatment of Rosacea- Johns Hopkins Review Article

General recommendations include a gentle skin care regimen to maintain skin hydration and barrier function, and photoprotection (sun exposure avoidance and sunscreen with a sun protection factor of 30 or greater).
Additionally, cover-up or color-correcting powders can be helpful to mitigate the psychosocial impact of rosacea. Since the psychosocial impact of rosacea tends to be underestimated by physicians, this issue should be raised with every patient and considered in the therapeutic plan.
Several topical drugs including topical metronidazole, azelaic acid, ivermectin, and brimonidine tartrate are approved for rosacea by the United States Food and Drug Administration (FDA).
The only (FDA) approved oral drug for rosacea is low-dose doxycycline. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003

Treatment of Rosacea- Johns Hopkins Review Article

- ...the only oral agent approved by the FDA to treat inflammatory rosacea lesions is a modified-release doxycycline (40 mg once-daily), which was approved in 2006.75 This once-daily 40 mg doxycycline dosing (30 mg immediate-release and 10 mg delayed-release beads) provides anti- inflammatory, without antimicrobial effects; in vivo microbiological studies demonstrated no long-term effects on bacterial flora of the oral cavity, skin, intestinal tract, and vagina.92-95

- Based on most current evidence, oral tetracycline (moderate quality evidence) and doxycycline (high quality evidence) were both associated with improvements in papulopustular rosacea compared with placebo.76 There was no difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse events with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence).76,94

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003

In my practice, I find that there has been little difference between the 40mg dose noted above and the (much) cheaper 50mg dose (without the different absorption profile). In my estimation, this difference in dosage and absorption is not significant for most, as doxycycline is largely absorbed through the liver pathway and has a lasting effect in oil glands (so that in some cases, even 50mg every other day can still have treatment value for rosacea patients). Azithromycin can have similar benefits for some rosacea patients (and can be available as a topical eye-drop preparation), so choice of which antibiotic (and by which route) can be customized by the physician for their patient.

For those who don’t do well with longer-term antibiotics (due to allergies, side effects, or as a preference), IPL can be a great option and can be used with or without antibiotics. Cost is often an issue, as most insurance programs will cover the antibiotics but will not cover IPL treatments. I’’ve posted extensively on IPL and will summarize this with some references, in my next posting (and can cover some of the other dermatological treatments recommended in the above review article). For more on doxycycline please also see my earlier post in this series, here: https://www.eyethera.com/blog/rosacea-and-dry-eyes-part-6 ).

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 6/30/24 Dr. Edward Jaccoma, MD 6/30/24

Rosacea and Dry Eyes Part 7 - the mental aspects of rosacea.

**Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis.**

Rosacea and related dry eye can have a host of impacts on a patient’s mental status (which also needs to be addressed and in many cases, also treated):

(adapted and annotated from: Woo YR, Han YJ, Kim HS, Cho SH, Lee JD. Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis. Int J Mol Sci. 2020 Nov 10;21(22):8427. doi: 10.3390/ijms21228427. PMID: 33182618; PMCID: PMC7696644.)

-Chronic pain syndrome (chronic erosive and corrosive impact on the surface of the eyes, with secondary irritation, inflammation) – eyes are important and help define our relationships to people, places and things. When eyes hurt, we may act out – or withdraw – with either reaction likely to affect our mental state.

-Anxiety/Body Dysmorphism (most have a degree of red eyes/lids/red face, many have frequent chalazia/styes, some have pustules (whitehead zits), papules (red bumps/zits), more rarely a phymatous (swollen) reaction. These changes can make us nervous and can negatively affect the way we see ourselves (dysmorphism).

-Depression (chronic anxiety, poor sleep, chronic, progressive nature of the disease) and slow, sometimes painful & painfully slow progress from treatments, with variable effects on vision, work performance, family life and the ability to enjoy common outdoor activities from weather impacts).

-High prevalence of GI issues associated with Rosacea. (poor absorption, increased circulating inflammatory mediators and abdominal pain with irregular bathroom habits and related social stressors).

Psychological aggravating factors such as stress, anxiety, personality issues with excessive feelings of shame and guilt, and social anxiety secondary to easy blushing could worsen the flushing in patients with rosacea and be a factor involved in the vicious cycle of rosacea.

-Known association with cardiovascular disorders (hypertension and coronary artery disease – adding additional psychic stress).

-Another chronic neurovascular disorder, migraine, shares a variety of clinical features with rosacea. Migraine and rosacea both have features of chronic, recurrent paroxysmal episodes with disabling symptoms in the trigeminal nerve (the nerve responsible for sensing pain in and around the eye as well as areas of the face). Indeed, Tan et al. first reported that 44% of the patients with rosacea had experienced migraines. Ocular rosacea appears to have a special connection to migraines, in that the more extreme “Phymatous” version of Rosacea is not commonly associated with migraine and Ocular Rosacea, is. It is also true that many of the “triggers” for rosacea are shared as equal triggers for migraines (especially the “vasoactive” foods like spices and alcohol, as well as extremes of hot and cold weather).

-Migraines independent of rosacea can be disabling with its own major effects on life-balance.

Because inflammation is central to many disease states, it should not be a stretch to understand that other neurological illnesses, such as Parkinson’s and Alzheimer’s Diseases are also more common in rosacea patients - though I should point out that there is much for medicine to learn about the intricacies of these “associations” and just because one has one disease, does not mean one is destined to acquire others.

This and future posting should help us understand why it often takes a village to best help our rosacea patients - with eye-affected ones requiring substantial assistance from eye care professionals.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 6/16/24 Dr. Edward Jaccoma, MD 6/16/24

Rosacea and Dry Eyes Part 6 - the Tetracyclines (including Doxycycline and Minocycline)

Fast forward 40,000 years from cave paintings (or so) and we have a better understanding of rosacea, including the biological underpinnings and stressors that drive this response today. Adapting and annotating from a Johns Hopkins Review Article: ‘stressors, including ultraviolet light from the sun, microbes (Demodex has stepped into the spotlight lately - see my post here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease ), trauma, emotional stress, and some hormones, may stimulate the release of “neurotransmitters” and contribute to the dilating blood vessels, flushing, and increased skin sensitivity, stinging, itch, and lower pain thresholds in patients with rosacea. Interestingly, pain fibers have been found to be increased in erythematotelangiectatic rosacea. Ion channels that regulate cell functions are (over) expressed in rosacea, on nerves, corneal surface cells, mast (allergy) cells and/or immune cells, making them highly reactive to thermal, chemical and/or mechanical stimulation.’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003

This was echoed and elaborated in a more recent review of Rosacea: “Dilation of lymphatic and blood vessels with exposure to extreme temperatures, spices, and alcohol has been observed in rosacea.” and “in addition, expression of matrix metalloproteinases (involved in inflammation) and vascular endothelial growth factor (invoved in blood vessel growth) is increased in rosacea. In rosacea, microbes may trigger activation of the immune response. This hypothesis is supported by an increased number of organisms, such as Demodex folliculorum on the skin and helicobacter pylori infection in the gut of patients with rosacea.”
https://www.ncbi.nlm.nih.gov/books/NBK557574/#article-28642.s5

The reason this is important, is that one of the more accepted treatments for rosacea is antibiotic therapy from the Tetracycline class (including Doxycycline and Minocycline). These antibiotics can interfere with the matrix metalloproteinases (reducing inflammation) and can kill helicobacter pylori (the bacteria commonly linked to stomach ulcers and thought to potentially lead to stomach cancers). These antibiotics are relatively cheap, often covered by health insurance plans and can be effective at reducing the skin and eye redness, sensitivity and irritation from rosacea. So why isn’t everyone with rosacea on these antibiotics?

Probably the number one reason is that these antibiotics don’t know the difference between “good” and “bad” germs - they simply take out any germ that is susceptible. This has the potentially adverse effect of encouraging resistant germs to “take over.” These can be yeast (not being a bacteria, they aren’t affected by these antibiotics and require specialized anti-yeast” medications to recover). Other germs with a drug-resistant profile are increasing in numbers and in their capacity for harm - but since they are resistant to most antibiotics, they pose a greater threat once they “turn bad” and cause diseases.

Fortunately, at the (low) dosages commonly recommended for treating rosacea, the effect on gut germs can be limited and this can potentially circumvent some of the harsher issues. But there are other issues that also need to be addressed. Because they are acidic in nature, they can be a little rough on a sensitive stomach - so taking them with food is often recommended. However foods containing calcium can bind to the antibiotic and make it difficult to absorb it (so it can run through the gut without getting into the bloodstream, where it would be needed to help fight facial and ocular rosacea). Probiotics like yogurt can help restore healthy germs to the gut after the antibiotic knocked them out. But yogurt is high in calcium, so while it is a good food for those taking these antibiotics, it is important to stagger the yogurt (or other calcium-rich foods) 1-2 hours before or after the antibiotic to allow optimal absorption. It is also advisable to not take the antibiotic right before bedtime, as it can get caught in the esophagus (before getting to the stomach) and cause ulcers or irritation (the stomach is naturally acidic and can usually easily handle it).

Add to that, the fact that it can negate the effects of birth control pills - but also is known to affect fetuses badly (causing birth defects) - so women of childbearing age need to be especially careful not to get pregnant while taking these antibiotics. It is also worth noting that patients who can sunburn - will be more prone to sunburning while taking these antibiotics. (It increases the damaging effects of Ultraviolet light on skin treated with the Tetracycline-type antibiotics - so it isn’t the drug that sunburns you - it is the sun that sunburns - just more easily). This means those on these antibiotics need to be extra careful when exposing themselves to the sun (covering up and wearing appropriate amounts of sun blocking lotions or creams). Taking them with a tall glass of water and a bit of bread or fruit after dinner - but at least an hour or two before bedtime can often allow them to do their best without significant stomach or lower gut side effects. Taking them at night can also limit the sunburning - (when the dose in the skin is the highest when there is no sunshine to sunburn.)

Lastly, it is possible to become allergic to the entire Tetracycline group from taking any one of these related antibiotics. This can be especially problematic for those who really need this particular antibiotic (like those with Lyme disease - where this is the preferred first line treatment against the Lyme organism). While the common allergic reaction is a rash, more severe allergies are possible - so when in doubt, best to immediately contact your doctor - or if not immediately available or in severe cases, to go immediately to the nearest Emergency Room.

Despite these potential adverse events and special considerations, Tetracyclines can be a good fit for many patients and side effects are usually easily mitigated - so I consider them on a case by case basis. There are also many treatment options apart from the Tetracyclines and it is best to work with a good dry eye specialist to determine what is best for you. We will delve further into this in future posts!

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 6/9/24 Dr. Edward Jaccoma, MD 6/9/24

Rosacea and Dry Eyes Part 5 - how did Rosacea “happen” to me?

Representation of a wild bovid, the Banteng, made in ochre, discovered in the Lubang Jeriji Saléh cave, East Kalimantan, Borneo, Indonesia, dated to 40 ka. Discovered in 1997 by Kalimanthrope (Pindi Setiawan, Luc-Henri Fage and Jean-Michel Chazine), it was dated to -40,000 BP in 2018 by Aubert & ali. and remains one of the oldest samples of figurative rock painting. This image appeared on Wikipedia's Main Page in the **Did you know?** column on 17 December 2018.

I’ve mentioned in a (much) earlier post that I have Rosacea, too. In thinking about how this might have “happened,” I like to think in evolutionary terms - and since it affects me, I like to think of it as a form of “higher evolution;)”

One of my premises about how dry eye evolved, begins with the notion that our great-great-great ancestors (thinking many hundreds of thousands of years ago and beyond) were characterized as the “hunter-gatherers.” These simple folk subsisted off the fish, nuts and seeds - or animals that ate the same fish, nuts and seeds (note the above cave drawing) - because way back then, there apparently was little else to eat back then. Those same folk generally lived in caves or some form of hovel (apart from the aristocracy that undoubtedly existed even then) - and lacking modern degrees of hygiene, one can assume these places were not up to today’s standards of cleanliness.

To survive as a species, we spent a lot of time hunting, gathering and procreating - but living in what we - today - would consider degrees of relative squalor, it was also obvious that we had to develop very strong immune systems to defend against the many germy threats that undoubtedly existed even then (and maybe especially then). Even as recently as Medieval times, we have history books that chronicle outbreaks of plagues, cholera, typhus and the like, which most historians blame on poor hygiene habits.

Without electricity, our ancestors were largely at the mercy of the sun for light, and to hunt and gather, most would likely spend the bulk of their days out in the wind and sun (where we learned to “blink strong” - a habit that would serve us well when it came to producing oil from our eyelid oil glands). The “peasant diet” of fish, nuts and seeds also served to supply the essential “building blocks,” which would nourish those same oil-producing glands - so our ancestors were oil producing machines - well adapted to the harsh environments we habitated - even if our life spans were pathetically short in those hard times.

Fast-forward to the past 100 years and there has been a huge increase in our lifespan (I commonly see patients in their 80s-90s and some 100s, when the average prehistoric was apparently 20s-30s to be considered an old man or woman). Add to that, the benefit of a controlled environment - clean, well lit and with a temperature regulated by HVAC systems that can keep our room temperature as warm or cold as we wish - and “life is good.”

Digital devices keep us connected around the globe, providing access to education and entertainment that even the enlightened Leonardo Da Vinci might not have dreamed of. Food has become relatively plentiful for the average American, too. Unfortunately, the foods we crave today generally are weak in the oil “building blocks” our ancestors ate (their fish, nuts and seeds being a rich source of Omegas 3,6 and 9). Scientists claim we Americans eat 95% less of these “essential oils” in the last 100 years, thanks to “processed foods” like Pizza, Pasta, Hamburgers, Hot Dogs (sorry Joe) and all the chips and pretzels we munch while watching those athletes who train and perform in the sun and wind while we relax indoors on a comfortable couch or lounge chair (except for Joe). Staring at those digital devices trains the oil-producing glands not to work (where strong blinks are the triggers that make them work).

Finally, we turn to the issue of Rosacea. We all carry genes programed in our immune systems to fight germs and provide lethal forces to the surface of the eye when it is sending SOS-distress signals to our defense system. Some of us (with rosacea genes) are more “programed” than others to “fight the good fight” - even if that means interpreting mild, innocuous germs as “the enemy” and sending our defenses into high gear when they should be on idle. We “Rosaceans” (I may have just cloned that word?) will gradually develop ruddy red faces, thanks to the dilating blood vessels carrying those potent defenses. Eyes can get red (and dry), too. Was this a “survival mechanism” that allowed some of us to better subsist and ultimately procreate in those dirty caves, so we could launch the next generation? Tough to think of it that way, but maybe that was the genetic hack that was needed in those harsh times - and here we are today, paying another price in older ages than those forebears would have imagined. That price can be a form of dry eye disease where the oils we produce can be more like a pro-inflammatory “kerosene” (my euphemism for the harsh oils common to rosacea) than like the healthy meibum oils we would wish for in our tears. More on this and the treatments to help with this, in my future posting.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 5/27/24 Dr. Edward Jaccoma, MD 5/27/24

Rosacea and Dry Eyes Part 4 - why eye doctors get involved.

There is general agreement that Ocular Rosacea (OR) is common, under-recognized and under-treated. Yet the consequences of OR can be severe and sight threatening.

This article published a review of records from 131 patients who had Ocular Rosacea (OR) and were seen and treated by corneal specialists in referral practices (so not the average eye care clinic). Clearly some of these patients had been referred by general eye doctors because they had exhausted treatments they could offer locally - so **this group of patients might be regarded as the “worst of the worst,”** as opposed to the more average patients with more average/milder levels of eye diseases.

**A “foreign body sensation” is also described as “a scratchy feeling” (like something got in the eye)** and is perhaps one of the most common presenting complaints eye doctors see, along with **burning** (and, in pollen season, itching). **Telangiectasias are the dilated, otherwise small blood vessels** I described in the opening segment of ths series on Rosacea. **Irregularities of the eyelid margin are common among those with chronic “blepharitis”** (inflammation of the lids) and in those with a history of styes (which are also common in Rosacea patients). **Meibomian Gland Dysfunction (or MGD) is an active cause of dry eye disease in up to 85% of sufferers** - so while any one of these findings are beyond common to the majority of patients eye doctors see, **the combination of these problems will most often indicate Ocular Rosacea**. That 13 of these patients (or 10%) had compromised corneas which also compromised their vision is scary and even scarier is that six of these patients (roughly half) required corneal transplants (Penetrating Keratoplasty) in an attempt to restore their vision. Cicatrizing conjunctivitis is when there is scarring of the membrane over the white of the eye - which can lead to an inability to move the eye without causing pain and/or double vision and can lead to an inability to fully close the eye.

We will get into treatment strategies for Rosacea in general, and Ocular Rosacea in particular in future posts. Of note, is that some of the patients in this series were left legally blind and one lost their eye as an uncommon but frightful result of this disease. Since this disease affects both skin and eyes, it may require the combined skills and efforts of skin (dermatologists) and eye doctors (optometrists and ophthalmologists). It also requires eye doctors to “step back” and look at the whole face of their patients (and for skin doctors to also look at their patients eyes).
*To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:*
*(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020*
*(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463*

Dr. Edward Jaccoma, MD 5/19/24 Dr. Edward Jaccoma, MD 5/19/24

Rosacea and Dry Eyes Part 3 - Commonly Associated Skin Conditions

**Telangiectasias** are when tiny blood vessels called capillaries become dilated and occur 4 times more commonly in people with **Rosacea**. **Spider veins** are even larger dilated vessels and a **hemangioma** is a cluster of dilated vessels creating a small, red patch. **Nevus Flammeus is another word for a “Port Wine Stain”** - seen as a birthmark that looks like a “splash” of ruby red wine - and caused by a larger group of dilated blood vessels. In this study, men dominated the abnormal vessel frequency (except for the hemangiomas).

Rosacea is the genetic tendency for sensitive skin and irritable oil glands. I see these dilated blood vessels as a direct consequence of this sensitivity, though one could debate which came first, the dilated vessel or the sensitivity. Increasing blood flow will bring the immune system with it and thereby make skin more sensitive, even as the sensitivity can “call” more blood vessels up to the surface to bring the immune system to where it can act on whatever caused the sensitive reaction. (The old “which came first, the chicken or the egg.?” argument.)

**Eczema is another word for sensitive skin and can come in as many as 7 different guises:** https://nationaleczema.org/eczema/types-of-eczema/
**Contact dermatitis** is form of eczema causing a reaction of the skin to something that it comes into contact with (like the red, itchy blistery rash from poison ivy). Once skin is sensitized to something, anytime it comes in contact with “that thing,” it will react - typically more severely with subsequent contact.

https://www.mayoclinic.org/diseases-conditions/contact-dermatitis/symptoms-causes/syc-20352742#dialogId5001370
This is an excellent example from the Mayo Clinic, of patients I commonly see with contact dermatitis. They note:
**Contact dermatitis on the face**
Contact dermatitis often affects skin directly exposed to an offending substance. Here, the rash is likely caused by cosmetics.

https://www.medicalnewstoday.com/articles/seborrheic-dermatitis-vs-eczema
**Seborrheic Dermatitis** is another common form of eczema that is frequently seen in patients with rosacea. It tends to affect oily skin such as the face and scalp. This fellow’s lids are affected along with most of his face.
Each form of eczema requires its own type of treatment, and the area affected along with the degree of involvement will dictate the best treatment required. This will sometimes require the combined efforts of skin (Dermatologists) and eye specialists. In each case, if rosacea is an undercurrent, then that aspect should also be appropriately treated - along with any associated dry eye and related ocular surface diseases. More on this to come!
*To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:*
*(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020*
*(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463*

Dr. Edward Jaccoma, MD 5/12/24 Dr. Edward Jaccoma, MD 5/12/24

Rosacea and Dry Eyes Part 2 - How Common Is It?

Dall'Oglio F, Fusto C, Micali G. Intrafamilial Transmission of Rosacea Spanning Six Generations: A Retrospective Observational Study. J Clin Aesthet Dermatol. 2022 Feb;15(2):35-39. PMID: 35309876; PMCID: PMC8884184.
In this study spanning 6 generations of families related to patients with rosacea, there was a high familial association (which in this figure, shows how early in life - as in this grandfather, the disease can be minimally noticeable until much later in life). Further: “The results showed that 64 of 130 patients (49.2%) were positive for at least a family member with rosacea. In addition, 90 affected relatives (69.2%) were identified by extending the familial investigation to the whole kindred, finding a percentage of familiarity (69.2%) higher than that reported in the literature (30-50%) with a 1:1.4. ratio of patients positive for familiarity/affected relative.”

As a dry eye specialist, I tend to see a lot of Ocular Rosacea due to the common association with dry eye. Since all forms of Rosacea can have ocular-related components, I look closely at faces as well as lids and eyes, for signs of this disease. But just how common is Rosacea in the general population? According to a large German study which involved experienced Dermatologists doing the examination on over 161,000 employed German people from many kinds of jobs, the incidence was only 1 in 50 people, though it was closely tied to age - with those over 60 being the most affected (approaching 6%).

Yet when compared to a global analysis taking 26.5 million adults into consideration, the incidence appears closer to more than 1 in 20 people over 18 years old being affected. Interestingly, in my practice (heavily weighted to dry eye sufferers over 18 years of age), I’d say Ocular Rosacea (as determined with microscopic evaluation of the eyelids) is even more common than that. So what does this mean? Well, it really doesn’t matter how many people don’t have it, if you do. Fortunately there are good treatments for this and they work better when caught early and treated effectively.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 4/29/24 Dr. Edward Jaccoma, MD 4/29/24

Rosacea and Dry Eyes - a common pairing that needs recognition and treatment!

In simplest terms, Rosacea is sensitive skin and irritable oil glands. It commonly runs in families and is most obvious in those with pale skin but can affect any colored skin type (with darker skin harder to see the redness in, but can be no less affected than their pale-skinned friends). There are 4-subtypes and each can be graded from mild to severe (see my slides below). Because eyes are often affected - and eye doctors use microscopes to examine the eyelids and look closely at their patient’s faces, we frequently are the first to diagnose Rosacea (before their PCPs and often, even their Dermatologists do).

How Red is my face? ETR is all about the redness. Telangiectasias are the fine, red, “spider lines” caused by dilated superficial blood vessels. Less superficial vessels can dilate more broadly and give the general red hue to those affected.

“I’m too old for zits!” Papulopustular Rosacea fits the “Rosacea as Adult-Acne” theme. Papules are red bumps, and pustules are “white-headed zits.” Erythema is the undercurrent of facial redness like the ETR type listed above.

Why is my nose swelling up? Phymatous Rosacea is sometimes referred to as the W. C. Fields’ “Whiskey Nose,” but does not need alcohol to trigger it.. Even emotional flushing with the right genetic makeup can fuel it. Swollen vessels carry lots of blood and the thinner walls of the dilated vessels can leak clear blood-fluids rich in growth factors - acting like fertilizer to affected skin and making it grow thicker and bigger.

A common cause of chronic “red eye” (though there are many others) - most patients will have both eyes affected - but not always equally - and styes are common. This type can occur in conjunction with any of the above rosacea subtypes but can also occur by itself or before the other types become obvious. Once it affects the clear window of the eye called the cornea, severe damage can occur (typically, KERATITIS - a form of inflammation that can lead to scarring and loss of vision if central, or less commonly, ULCERS - a thinning and weakening of the cornea commonly related to infections that can lead to perforation and loss of the eye).

Since Rosacea can have devastating consequences for significantly affected eyes and eyelids, recognition is key as it should then lead to proper treatments. Even modestly affected eyes can have real - if not devastating consequences, I find most dry eye specialists to be uniquely suited to helping their patients with Rosacea - and future pasts will help to further explain the nature of Rosacea - the (good and bad) things that can affect it and some of the better treatments we can use to make it better.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Dr. Edward Jaccoma, MD 4/21/24 Dr. Edward Jaccoma, MD 4/21/24

News Updates - more bad drops on the market and a new kind of “punctal plug” - Lacrifill!

First the bad news - FDA warnings about drops that could infect or injure you, continue:
”[1/31/2024] FDA is warning consumers not to purchase or use South Moon, Rebright or FivFivGo eye drops because of the potential risk of eye infection.

These are copycat eye drop products that consumers can easily mistake for Bausch + Lomb’s Lumify brand eye drops, an over-the-counter product approved for redness relief.” https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-consumers-contaminated-copycat-eye-drops?fbclid=IwAR085_VOsxm-9x0CtykAzUJF2Fb4Rn2nQzBFAd7HYsdwc6EBKu31z9hy_jI_aem_AfyHpReFyoRIaWRypfQKaucUi2WHDOhHkA7HxmLNfxqe1dwwFHXGJmlWgjMWkFb2a-A

I posted on Lumify (and other eye whiteners) - and the risks taken even with on-brand drops like these here: https://www.eyethera.com/blog/can-i-use-eye-whiteners-like-visine-or-lumify-when-my-eyes-get-red

Now the better news -

April 7, 2024, I attended the American Society of Cataract and Refractive Surgery annual meeting. While I no longer perform cataract or refractive surgery, I see patients who have cataracts, and who may be planning cataract surgery, nearly every day in my clinical dry eye practice. I’ve posted on cataracts and dry eyes here: https://www.eyethera.com/blog/dry-eye-cataract-and-glaucoma-segment Control of the ocular surface is critical to a good outcome with cataract surgery, so I am often involved in the pre (and post) operative care of these patients. During that meeting, a new punctal plugging product. was rolled out, called “Lacrifill.” It is basically a sugar gel like “Juvederm” or “Restylane” (a natural “hyaluronic acid” compound found in skin and eyes) that has long been used as a filler in cosmetic procedures and in cataract surgery. It will gradually dissolve into sugar and water, so needs replacement approximately every 6 months (& may last a bit longer - or less long, for some). If it works “too well” and results in chronic, unwanted tearing (down the cheeks), then a salt water solution can be used to rinse it down the “plumbing” into the nose. There is also an enzyme that can dissolve it in cases that a simple rinsing doesn’t work (expected to be rare). Insurance is expected to cover it, as a plugging procedure, but it’s possible that some may require a “prior authorization” approval process. Punctal plugging is not for everyone (I’ve blogged about this before: https://www.eyethera.com/blog/what-about-punctal-plugs-or-why-not-dam-up-those-damn-tears and https://www.eyethera.com/blog/when-tears-dont-drain-properly-you-get-toxic-soup-and-the-toxic-soup-syndrome

While these prior posts cover most of the potential “negatives” involved with blocking the normal flow of tears from the eye to the nose, it is true that there are numbers of patients who will significantly benefit from such tear duct closure. Keeping more tears (and any medicated products) on the surface of the eyes is hepful when the tears are “good tears” but just too little to do their job. A potential benefit of this unique use of sugar gel, is the “soft” and “sticky” quality of this natural filler. This means no “plastic” is exposed to the delicate membranes of the eye, and nothing to “fall out,” which is a common problem with the plastic plugs that are “wedged” into the tiny tear duct openings along the inner eyelid margins. Lacrifill can “hug” the passageways leading from the eyelid to the nose, blocking tears along the entire way.

A few key points - as a sugar gel, the reason it doesn’t instantly “dissolve” into sugar and water, is due to the “crosslinking” where the sugar molecules are bound strongly to each other. Natural enzymes break these links down over time and the more “links” in the chain, the harder it is to break down. Staying soft and “gel-like” means that excessive manipulation (squeezing, massaging, rubbing) may cause some gel to “burp out” of the tear duct (either into your tears, or down your nose), so avoidance of excess manipulation near the tear drainage area should generally be avoided with this product (especially in the first days of instillation, as most sugar gels tend to “set up” and become more locked in place as they mature in their position). If too much burps out and into your tears, this leaves a portion of the duct “empty” with a blockage in place closer to the nose. Typically, this can lead to a “stagnant pool” of tears where germs can thrive and potentially cause infections. If the area of the lids closer to the nose become infected, then sticky yellow-to-greenish discharge and/or redness, swelling, tenderness and warmth of that area can indicate an urgent need to see your eye doctor.

As usual, I recommend working with a dry eye specialist to get the best results for your dry eyes.

To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:

(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020

(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463

Blog

FDA warns consumers of contaminated copycat eye drops

Of potentially equal or greater concern (with Halloween around the corner) is this statement by the American Academy of Ophthalmology (AAO): “What Ophthalmologists Want You to Know About Eye Color-Changing Drops

Treatment of ocular Demodex infestation with topical ivermectin cream

Contact dermatitis on the face

Now the better news -