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