Conflicting Doctor Recommendations..

[Deniz]

I am confused..As some of you remember, I have had dry eyes since March, which I believe started due to extensive computer use and contact lense wear. My condition deteriorated since March and until recently (before lower punctual plugs) I had been using drops once in 5 minutes, especially if I am traveling. My eyes were almost always red, and always uncomfortable. I had lower punctual plugs in two weeks ago, and used steroids following the plug insert for one week. I started feeling normal with almost NO REDNESS OR DISCOMFORT with lotemax. After that one week, I stopped Lotemax, and started Restasis. From the first day, I felt an improvement with Restasis. After I used it for 4 days, I went to see this specialist ophthalmologist known for his work in dry eyes.

Despite what the 8-9 doctors before him told me, he told me I did not have an issue with my tear production, but had a condition called ocular rosecea. He said he understood that I had this condition from the first moment I walked in the office!! Mind you, I was all red after walking for 1 hour before coming to the office, and had a couple of small pimples (I am premenstrual!) that I scratched.. He told me my condition was mild and chronic, told me to to get off any chemicals, get off restasis, keep the plugs for now. He said no contacts, no make up, no lasik - at least until summer..

I really don't think I have ocular rosecea for a couple of reasons: 1) nothing as such in my family 2) not common in my genetic pool - I am from Turkey which is Mediterranean/ Middle East 3) Though very fair, I have perfect skin except for premenstrual period. 4) if I have enough tear production, why did the plugs work, why did restasis work?? why do I have trouble crying, and feel dry all the time??

I have decided to ignore this doctors recommendation, and continue with the other doctors' diagnosis. I am not sure about this, but I really do not want to continue to use drops every hour/ or even more frequent if restasis can help..Also, I want to be able to use make up..

I need some help. What do you guys think I should do? I have an appointment in for a doctor in Cornell University but not before December..

Thanks so much for you help.

[Rebecca Petris]

Deniz,

Despite what the 8-9 docs before this one said, I'd sure take what this one said seriously. The thing with ocular rosacea is that it clogs the meibomian glands so if I understand your new doc correctly, the point really is that you have meibomian gland dysfunction (secondary to ocular rosacea). MGD is so frequently undiagnosed - though thankfully that's starting to change - that the conflicting opinions are understandable. It's one of my greatest frustrations about dry eye care.

The confusing thing about dry eye is that no matter what the cause, the common treatments (plug & drop etc) will often provide at least some relief. The whole thing is very complex and there's not necessarily any nice neat correlation that says "It's JUST aqueous so treat the aqueous" or "It's JUST MGs so treat the MGs and you'll feel better".

Did this new doc actually say you are NOT aqueous deficient? On what basis - was there a schirmer test, staining, other?

As for Restasis, there are conflicting reports about this. I think there are people out there with MGD who say it's helping them and doctors who believe it does. But unfortunately you're never going to get a consensus about it. If you go to yet another doctor it's not necessarily going to give you more clarity than you have now. It's just kinda up to you to decide whose advice you want to go with. Personally I think the best way to tackle this stuff is, be consistent and try as much as possible to give any new treatments a decent trial without introducing other variables if you can.

As for the MGD... If that is the problem, there's a number of things to try including warm compresses, omega 3s, oral antibiotics. (You can check all these out in our Dry Eye A to Z.)

[kaypeeoh]

I did a search on google.scholar and got hundreds of hits so it must be a common occurance. This is 10 years old:

Ocular rosacea. Signs, symptoms, and tear studies before and after treatment with doxycycline
M. J. Quarterman, D. W. Johnson, D. C. Abele, J. L. Lesher Jr, D. S. Hull and L. S. Davis
Department of Medicine, Medical College of Georgia, Augusta, USA.

OBJECTIVE: To examine ocular signs, symptoms, and results of tear analysis in patients with cutaneous rosacea before, during, and after doxycycline therapy. DESIGN: Before-after trial. SETTING: General community. PATIENTS OR OTHER PARTICIPANTS: Thirty-nine patients with cutaneous rosacea underwent dermatologic and ocular examinations, testing of tear break-up time, and Schirmer testing at baseline and 4, 8, and 12 weeks. Six patients did not complete the study. Baseline tear break-up time and results of Schirmer test were compared with those of 13 patients without rosacea who were matched for age and sex. INTERVENTION: Patients with rosacea were given doxycycline, 100 mg daily for 12 weeks. MAIN OUTCOME MEASURE: Statistically significant (P, .05) improvement in tear break-up time. RESULT: The most frequent ocular symptoms were dryness, itching, blurred vision, and photosensitivity, all of which improved significantly with treatment. All patients had signs of ocular disease, most commonly erythema and telangiectasia, meibomian gland dysfunction, and ciliary base injection. Significant improvement (P,.05) for scales, erythema and telangiectasia, ciliary base injection, bulbar injection, papillary hypertrophy, and punctate epithelial erosions was seen. Average tear break-up time for the patients with rosacea was 5.7 seconds, which improved to 10.8 seconds after 12 weeks of treatment (P = .007). Baseline tear break-up time was significantly lower than for the comparison group of normal subjects (P = .001). There was no correlation between severity of cutaneous disease and ocular disease. CONCLUSIONS: All patients with cutaneous rosacea had some degree of ocular involvement. Tear break-up time is abnormal in patients with rosacea. Ocular erythema and telangiectasia, meibomian gland dysfunction, and short tear break-up time in patients with cutaneous rosacea are indicators of ocular rosacea. Doxycycline, 100 mg daily, will improve ocular disease and increase the tear break-up time.

[Rebecca Petris]

Bingo! Thanks Kevin.

"...There was no correlation between severity of cutaneous disease and ocular disease. CONCLUSIONS: ...meibomian gland dysfunction, and short tear break-up time in patients with cutaneous rosacea are indicators of ocular rosacea. Doxycycline, 100 mg daily, will improve ocular disease and increase the tear break-up time.

[indrep]

Deniz,

4) if I have enough tear production, why did the plugs work, why did restasis work?? why do I have trouble crying, and feel dry all the time??

It may appear that you have enough tear production with the plugs inserted. Your tear lake would be sufficient and Schirmer's would show enough tear. Unfortunately with the MGD your tears are evaporating quickly. So the plugs are keeping enough tear on your eye to comfort it.

You may have secondary inflammation due to the osmolarity of your tear film having changed since March and the Restasis helped reduce the inflammation. Or you were feeling relief from the plugs and the Restasis hasn't had an impact.

Your nourishing, maintenance tears are far different than emotional or pain tears. Could be unrelated.

Bottom line is I would take seriously the MGD issue and try to improve that because the other treatments are not going to be at their most beneficial if the tears are evaporating.

[Deniz]

Thanks

Thanks for all your messages. After reading the posts, I realize that I have not done my homework in understanding eye anatomy and my disease. Therefore I will take the time to post a response and do some research.Thanks again!

Regards,

D

[SusieD]

Quite recently there was an article in Ophthalmology times that showed positive results with restasis in patients with ocular rosacea. Dr Latkany thought I had a degree of ocular rosacea and said he had seen restasis help. If you were feeling some benefit from it, I see no reason not to continue.

Sorry I dont have the link to the article will try to find it - it was 2006 though.