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Vassileva S, Tanev I, Drenovska K. Rosacea: The eyes have it. Clin Dermatol 2023; 41:528-536. [PMID: 37591470 DOI: 10.1016/j.clindermatol.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Rosacea is a chronic inflammatory dermatosis typically affecting the facial skin but also the eyes. With its chronic course with fluctuating episodes of flashing, redness, papulopustules, and nodules it poses a severe psychologic burden to the affected individuals. In addition to the facial changes, more than half of the patients have ocular involvement ranging from blepharitis and conjunctival hyperemia to more severe ophthalmic damage, and even blindness. Clinically, the ocular involvement in rosacea includes meibomian gland dysfunction with relapsing hordeola and chalazia, diffuse hyperemic conjunctivitis, photophobia, episcleritis, or kerato-conjunctivitis, and in rare cases, corneal ulcers. These are mainly observed in adult patients but can also occur in children. Depending on the degree of cutaneous or ocular findings, patients with rosacea may present first to the dermatologist or to the ophthalmologist. Both specialists should be aware of the potential oculocutaneous involvement. Any ocular complaints expressed by the patient in the setting of a dermatologist's office should be referred promptly for an ophthalmologic examination. Conversely, signs suggestive of rosacea in the eye should lead the ophthalmologist to consider underlying skin disease. A timely interdisciplinary collaboration is paramount for the earlier diagnosis and treatment, thus preventing permanent eye impairment in this chronic dermatosis.
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Affiliation(s)
- Snejina Vassileva
- Department of Dermatology and Venereology, Medical University - Sofia, Sofia, Bulgaria.
| | - Ivan Tanev
- ZRENIE Private Eye Clinic, Sofia, Bulgaria
| | - Kossara Drenovska
- Department of Dermatology and Venereology, Medical University - Sofia, Sofia, Bulgaria
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Abstract
BACKGROUND Posterior blepharitis is common and causes ocular surface and lid damage as well as discomfort. It affects 37% to 47% of all ophthalmology patients; its incidence increasing with age. It is a multifactorial disease associated with multiple other pathologies, such as rosacea, meibomianitis, and infections. Treatment usually focuses on reliefing the symptoms by using artificial tears, lid scrubs, and warm compresses. The condition may be notoriously difficult to manage adequately once it becomes chronic. One such management approach for chronic blepharitis is the use of oral antibiotics for both their antibacterial as well as anti-inflammatory properties. There are currently no guidelines regarding the use of oral antibiotics, including antibiotic type, dosage, and treatment duration, for the treatment of chronic blepharitis. OBJECTIVES To assess the benefits and harms of oral antibiotic use for people with chronic blepharitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 8); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 29 August 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing oral antibiotics with placebo in adult participants with chronic blepharitis (including staphylococcal, seborrhoeic, or Meibomian Gland Dysfunction (MGD)). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology and graded the certainty of the body of evidence for six outcomes using the GRADE classification. MAIN RESULTS We included two studies with 220 participants (numbers of eyes unclear). One parallel-group RCT comparing oral doxycycline (40 mg once a day) with placebo enrolled 70 participants with blepharitis and facial rosacea in the USA. Follow-up duration was three months. One three-arm RCT conducted in South Korea investigated the effect of high-dose (200 mg twice a day) and low-dose (20 mg twice a day) doxycycline versus placebo after one month of study medication. It enrolled 50 participants with chronic MGD in each study arm (i.e. 150 participants enrolled in total). The two studies did not evaluate the same outcome measurements, which precluded any meta-analysis. The evidence for the effect of oral antibiotics on subjective improvement in symptoms was very uncertain. One study suggested that there was little to no effect of oral doxycycline on subjective symptoms based on the Ocular Surface Disease Index (OSDI) scores ranging from 0 to 100 (higher score indicates worse condition) (mean difference (MD) 3.55, 95% confidence interval (CI) -4.61 to 11.71; n = 70) and bulbar conjunctival hyperemia ranging from 0 (clear) to 4 (severe) (MD -0.01, 95% CI -0.38 to 0.36; n = 70) at 12 weeks. The three-arm RCT showed that oral doxycycline may slightly improve number of symptoms (MD -0.56, 95% CI -0.95 to -0.17; n = 93 (high-dose doxycycline versus placebo); MD -0.48, 95% CI -0.86 to -0.10; n = 93 (low-dose doxycycline versus placebo)) and proportion of participants with symptom improvement (risk ratio (RR) 6.13, 95% CI 2.61 to 14.42; n = 93 (high-dose doxycycline versus placebo); RR 6.54, 95% CI 2.79 to 15.30; n = 93 (low-dose doxycycline versus placebo)) at one month, but the evidence is very uncertain. We judged the certainty of evidence for subjective symptoms as very low. One study evaluated aqueous tear production by Schirmer's test (mm/5 min) (higher score indicates better condition) and tear film stability by measuring tear film break-up time (TBUT) in seconds (higher score indicates better condition) at one month. We found very low certainty evidence that oral doxycycline may improve these clinical signs. The estimated MD in Schirmer's test score after one month of treatment was 4.09 mm (95% CI 2.38 to 5.80; n = 93) in the high-dose doxycycline group versus the placebo group and 3.76 mm (95% CI 1.85 to 5.67; n = 93) in the low-dose doxycycline group versus the placebo group. The estimated MD in TBUT after one month was 1.58 seconds (95% CI 0.57 to 2.59; n = 93) when comparing the high-dose doxycycline group with the placebo group, and 1.70 seconds (95% CI 0.96 to 2.44; n = 93) when comparing the low-dose doxycycline group with the placebo group. Although there was a noted improvement in these scores, their clinical importance remains uncertain. One study suggested that oral doxycycline may increase the incidence of serious side effects: 18 (39%) participants in the high-dose doxycycline group, 8 (17%) in the low-dose doxycycline group, and 3 (6%) out of 47 participants in the placebo group experienced serious side effects (RR 6.13, 95% CI 1.94 to 19.41; n = 93 (high-dose doxycycline versus placebo); RR 2.72, 95% CI 0.77 to 9.64; n = 93 (low-dose doxycycline versus placebo)). Additionally, one study reported that one case of migraine headache and five cases of headache were observed in the oral doxycycline group, and one case of non-Hodgkin's lymphoma was observed in the placebo group. We judged the certainty of evidence for adverse events as very low. AUTHORS' CONCLUSIONS There was insufficient evidence to draw any meaningful conclusions on the use of oral antibiotics for chronic blepharitis. Very low certainty evidence suggests that oral antibiotics may improve clinical signs, but may cause more adverse events. The evidence for the effect of oral antibiotics on subjective symptoms is very uncertain. Further trials are needed to provide high quality evidence on the use of oral antibiotics in the treatment of chronic blepharitis.
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Affiliation(s)
- Neil Onghanseng
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Sueko M Ng
- Department of Ophthalmology, School of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University, Palo Alto, California, USA
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Ganesalingam K, Ismail S, Sherwin T, Craig JP. Molecular evidence for the role of inflammation in dry eye disease. Clin Exp Optom 2021; 102:446-454. [DOI: 10.1111/cxo.12849] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/13/2018] [Accepted: 10/07/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Kalaivarny Ganesalingam
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand,
| | - Salim Ismail
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand,
| | - Trevor Sherwin
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand,
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand,
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Trufanov SV, Shakhbazyan NP. [Ophthalmic Rosacea: etiopathogenesis and modern treatment methods]. Vestn Oftalmol 2018; 134:121-128. [PMID: 29953092 DOI: 10.17116/oftalma20181343121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Rosacea is a multifactorial chronic inflammatory disease with various clinical manifestations. Primarily it is seen as a dermatological condition, but it's not uncommon for it to develop ophthalmological implications affecting eyelids, cornea and conjunctiva. The article describes main aspects of its etiopathogenesis, variations in its clinical course and treatment approaches. There is currently no universal treatment strategy for the disease due to its varying clinical manifestation, particularly of its ophthalmological form, differing severity of the pathological process, lack of knowledge about its etiology and pathogenesis. Leading role in its pathological process belongs to disturbance of regulatory mechanisms of the vascular, immune and nervous systems. Additionally, higher levels of metalloproteinases and vascular endothelial growth factor (VEGF) can be observed. Possible influence of a range of micro-organisms also hasn't been excluded. Basic therapy involves both systemic and topical drugs. The first include tetracycline antibiotics. A new direction in Rosacea treatment that aims at structural and functional restoration of vascular endothelium, improvement of microcirculation and recovery of rheological properties of blood is angioprotector therapy, in particular with Calcium Dobesilate (Doxi-Hem). Aside from systemic drugs, the ophthalmological forms of Rosacea are treated topically with anti-inflammatory preparations, immunosuppressants and artificial tears that are chosen depending on the symptoms' severity. In cases with heavy corneal damage, various types of keratoplasty can be performed. Collaboration between ophthalmology and dermatology specialists is necessary in order to choose adequate strategy for Rosacea treatment.
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Affiliation(s)
- S V Trufanov
- Research Institute of Eye Diseases, 11A, В Rossolimo St., Moscow, Russian Federation, 119021
| | - N P Shakhbazyan
- Research Institute of Eye Diseases, 11A, В Rossolimo St., Moscow, Russian Federation, 119021
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Anzengruber F, Czernielewski J, Conrad C, Feldmeyer L, Yawalkar N, Häusermann P, Cozzio A, Mainetti C, Goldblum D, Läuchli S, Imhof L, Brand C, Laffitte E, Navarini AA. Swiss S1 guideline for the treatment of rosacea. J Eur Acad Dermatol Venereol 2017; 31:1775-1791. [PMID: 28833645 DOI: 10.1111/jdv.14349] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/08/2017] [Indexed: 12/28/2022]
Abstract
Rosacea (in German sometimes called 'Kupferfinne', in French 'Couperose' and in Italian 'Copparosa') is a chronic and frequently relapsing inflammatory skin disease primarily affecting the central areas of the face. Its geographic prevalence varies from 1% to 22%. The differential diagnosis is wide, and the treatment is sometimes difficult and varies by stage of rosacea. For erythematous lesions and telangiectasia, intense pulsed light (IPL) therapy and lasers are popular treatment option. In addition, a vasoconstrictor agent, brimonidine, has recently been developed. For papulopustular rosacea, topical antibiotics, topical and systemic retinoids, as well as systemic antibiotics are used. A topical acaricidal agent, ivermectin, has undergone clinical development and is now on the market. In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. Here, we reviewed the current evidence on the treatment of rosacea, provide a guideline (S1 level) and discuss the differential diagnosis of rosacea.
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Affiliation(s)
- F Anzengruber
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - J Czernielewski
- Department of Dermatology, University Hospital Lausanne, Lausanne, Switzerland
| | - C Conrad
- Department of Dermatology, University Hospital Lausanne, Lausanne, Switzerland
| | - L Feldmeyer
- Department of Dermatology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - N Yawalkar
- Department of Dermatology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - P Häusermann
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - A Cozzio
- Department of Dermatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - C Mainetti
- Department of Dermatology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - D Goldblum
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - S Läuchli
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - L Imhof
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - C Brand
- Department of Dermatology, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - E Laffitte
- Department of Dermatology, University Hospital Geneva, Geneva, Switzerland
| | - A A Navarini
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
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Jones L, Downie LE, Korb D, Benitez-del-Castillo JM, Dana R, Deng SX, Dong PN, Geerling G, Hida RY, Liu Y, Seo KY, Tauber J, Wakamatsu TH, Xu J, Wolffsohn JS, Craig JP. TFOS DEWS II Management and Therapy Report. Ocul Surf 2017; 15:575-628. [DOI: 10.1016/j.jtos.2017.05.006] [Citation(s) in RCA: 578] [Impact Index Per Article: 82.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
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González-López JJ, Bunce C, Rodriguez-Artalejo F. Characteristics of randomised trials in ophthalmology using a single eye per person design. Hippokratia 2016. [DOI: 10.1002/14651858.cd010799.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Julio J González-López
- Moorfields Eye Hospital NHS Foundation Trust; Medical Retina Service; 162 City Road London UK EC1V 2PD
| | - Catey Bunce
- Kings College London; Department of Primary Care & Public Health Sciences; 4th Floor, Addison House Guy's Campus London UK SE1 1UL
| | - Fernando Rodriguez-Artalejo
- Facultad de Medicina, Universidad Autónoma de Madrid; Public Health; Calle Arzobispo Morcillo, sin número Madrid Spain 28029
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Sy A, O'Brien KS, Liu MP, Cuddapah PA, Acharya NR, Lietman TM, Rose-Nussbaumer J. Expert opinion in the management of aqueous Deficient Dry Eye Disease (DED). BMC Ophthalmol 2015; 15:133. [PMID: 26462481 PMCID: PMC4604775 DOI: 10.1186/s12886-015-0122-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 09/30/2015] [Indexed: 01/05/2023] Open
Abstract
Background Dry eye disease (DED) affects millions of people worldwide. There are a variety of new treatments beyond traditional therapies such as preservative free artificial tears. Here, we conduct a survey to identify the most common treatments used among specialists and assess their interest in newer therapies. Methods An international survey was distributed to dry eye researchers and expert practitioners via an internet survey. The survey data collected were analyzed with descriptive statistics. Results One hundred and fifteen respondents completed the survey; of these, 66 % were cornea specialists. The most commonly prescribed topical treatments included cyclosporine A (CSA) 0.05 % (71/104, 68 %), fluorometholone (FML) 0.1 % (59/99, 60 %), loteprednol etabonate 0.5 % (50/99, 51 %), and autologous serum eye drops (ASD; 48/97, 49 %). The most commonly prescribed non-topical medications included essential fatty acid supplements (72/104, 69 %), low-dose doxycycline (oral; 61/100, 61 %), and flaxseed supplements (32/96, 33 %) as well as punctal plugs (76/102, 75 %). Respondents reported treatment with topical corticosteroids for 2 to 8 weeks (46/86, 53 %), followed by less than 2 weeks (24/86, 28 %) and with topical CSA between 2 to 8 weeks (45/85, 53 %) followed by 2 to 6 months (24/85, 28 %). The top three signs and symptoms reported to indicate treatment response were, in order, fluorescein staining of the cornea, reduction in foreign body sensation, and reduction in burning sensation. Conclusion This survey offers insight into current expert opinion in the treatment of DED. The results of this survey are hypothesis generating and will aid in the design of future clinical studies.
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Affiliation(s)
- Aileen Sy
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA. .,F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA.
| | - Kieran S O'Brien
- F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA.
| | - Margaret P Liu
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA.
| | - Puja A Cuddapah
- F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA.
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA. .,Department of Ophthalmology, University of California, San Francisco, CA, USA.
| | - Thomas M Lietman
- F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA. .,Department of Ophthalmology, University of California, San Francisco, CA, USA.
| | - Jennifer Rose-Nussbaumer
- F.I. Proctor Foundation, University of California, Room S309, 513 Parnassus Ave, UCSF, San Francisco, CA, 94143-0412, USA. .,Department of Ophthalmology, University of California, San Francisco, CA, USA.
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective. OBJECTIVES To assess the efficacy and safety of treatments for rosacea. SEARCH METHODS We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea. DATA COLLECTION AND ANALYSIS Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors. MAIN RESULTS We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence). AUTHORS' CONCLUSIONS There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.
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Affiliation(s)
- Esther J van Zuuren
- Leiden University Medical CenterDepartment of DermatologyPO Box 9600B1‐QLeidenNetherlands2300 RC
| | | | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & NeuroscienceBiostatistics and Health InformaticsDenmark HillLondonUK
| | | | - Lyn Charland
- The University of Nottinghamc/o Cochrane Skin GroupNottinghamUK
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Sadarangani SP, Estes LL, Steckelberg JM. Non-anti-infective effects of antimicrobials and their clinical applications: a review. Mayo Clin Proc 2015; 90:109-27. [PMID: 25440726 DOI: 10.1016/j.mayocp.2014.09.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 09/17/2014] [Accepted: 09/19/2014] [Indexed: 12/12/2022]
Abstract
Antimicrobial agents are undoubtedly one of the key advances in the history of modern medicine and infectious diseases, improving the clinical outcomes of infection owing to their inhibitory effects on microbial growth. However, many antimicrobial agents also have biological activities stemming from their interactions with host receptors and effects on host inflammatory responses and other human or bacterial cellular biological pathways. These result in clinical uses of antimicrobial drugs that are distinct from their direct bacteriostatic or bactericidal properties. We reviewed the published literature regarding non-anti-infective therapeutic properties and proposed clinical applications of selected antimicrobials, specifically, macrolides, tetracyclines, sulfonamides, and ketoconazole. The clinical applications reviewed were varied, and we focused on uses that were clinically relevant (in terms of importance and burden of disease) and where published evidence exists. Such uses include chronic inflammatory pulmonary and skin disorders, chronic periodontitis, gastrointestinal dysmotility, rheumatoid arthritis, and cancer. Most of these potential therapeutic uses are not Food and Drug Administration approved. Clinicians need to weigh the use of antimicrobial agents for their non-anti-infective benefits, considering potential adverse effects and long-term effect on microbial resistance.
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Affiliation(s)
| | - Lynn L Estes
- Hospital Pharmacy Services, Mayo Clinic, Rochester, MN
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Cuevas P, Outeiriño LA, Azanza C, Angulo J, Giménez-Gallego G. Improvement in the signs and symptoms of dry eye disease with dobesilate eye drops. Mil Med Res 2015; 2:35. [PMID: 26697189 PMCID: PMC4687099 DOI: 10.1186/s40779-015-0068-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 12/15/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dry eye is a multifactor disease of the tear film and ocular surface that substantially affects quality of life. CASE PRESENTATION Dobesilate administered as eye drops was well tolerated and effective in treating both the objective signs and subjective symptoms of dry eye disease in this 2-week study. CONCLUSION To the best of our knowledge, this is the first clinical report of using dobesilate in eye drops. Dobesilate may provide a novel approach to treating drying diseases of the eye.
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Affiliation(s)
- Pedro Cuevas
- Facultad de Medicina, Universidad Alfonso X, Madrid, Spain ; Departamento de Oftalmología, Hospital de Día Pío XII, Madrid, Spain
| | | | - Carlos Azanza
- Departamento de Oftalmología, Hospital de Día Pío XII, Madrid, Spain
| | - Javier Angulo
- Servicio de Histología. Departamento de Investigación, IRYCIS; Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Guillermo Giménez-Gallego
- Departamento de Estructura y Función de Proteínas, Centro de Investigaciones Biológicas. CSIC, Madrid, Spain
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Abstract
BACKGROUND Blepharitis, an inflammatory condition associated with itchiness, redness, flaking, and crusting of the eyelids, is a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopathy (abnormality of the cornea), corneal neovascularization, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low-grade infections of the ocular surface with bacteria, infestations with certain parasites such as demodex, and inflammatory skin conditions such as atopy and seborrhea. Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blepharitis. Second, categorization is based on the anatomical location of disease: anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. meibomian gland dysfunction (MGD)). This review focuses on chronic blepharitis and stratifies anterior and posterior blepharitis. OBJECTIVES To examine the effectiveness of interventions in the treatment of chronic blepharitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We searched the reference lists of included studies for any additional studies not identified by the electronic searches. There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 February 2012. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (CCTs) in which participants were adults aged 16 years or older and clinically diagnosed with chronic blepharitis. We also included trials where participants with chronic blepharitis were a subset of the participants included in the study and data were reported separately for these participants. Interventions within the scope of this review included medical treatment and lid hygiene measures. DATA COLLECTION AND ANALYSIS Two authors independently assessed search results, reviewed full-text copies for eligibility, examined risk of bias, and extracted data. Data were meta-analyzed for studies comparing similar interventions and reporting comparable outcomes with the same timing. Otherwise, results for included studies were summarized in the text. MAIN RESULTS There were 34 studies (2169 participants with blepharitis) included in this review: 20 studies (14 RCTs and 6 CCTs) included 1661 participants with anterior or mixed blepharitis and 14 studies (12 RCTs and 2 CCTs) included 508 participants with posterior blepharitis (MGD). Due to the heterogeneity of study characteristics among the included studies, with respect to follow-up periods and types of interventions, comparisons, and condition of participants, our ability to perform meta-analyses was limited. Topical antibiotics were shown to provide some symptomatic relief and were effective in eradicating bacteria from the eyelid margin for anterior blepharitis. Lid hygiene may provide symptomatic relief for anterior and posterior blepharitis. The effectiveness of other treatments for blepharitis, such as topical steroids and oral antibiotics, were inconclusive. AUTHORS' CONCLUSIONS Despite identifying 34 trials related to treatments for blepharitis, there is no strong evidence for any of the treatments in terms of curing chronic blepharitis. Commercial products are marketed to consumers and prescribed to patients without substantial evidence of effectiveness. Further research is needed to evaluate the effectiveness of such treatments. Any RCT designed for this purpose should separate participants by type of condition (e.g. staphylococcal blepharitis or MGD) in order to minimize imbalances between groups (type I errors) and to achieve statistical power for analyses (prevent type II errors). Medical interventions and commercial products should be compared with conventional lid hygiene measures, such as warm compresses and eyelid margin washing, to determine effectiveness, as well as head-to-head to show comparative effectiveness between treatments. Outcomes of interest should be patient-centered and measured using validated questionnaires or scales. It is important that participants be followed long-term, at least one year, to assess chronic outcomes properly.
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Affiliation(s)
- Kristina Lindsley
- Center for Clinical Trials, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,USA.
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Stevenson W, Chauhan SK, Dana R. Dry eye disease: an immune-mediated ocular surface disorder. ARCHIVES OF OPHTHALMOLOGY (CHICAGO, ILL. : 1960) 2012; 130:90-100. [PMID: 22232476 PMCID: PMC3677724 DOI: 10.1001/archophthalmol.2011.364] [Citation(s) in RCA: 411] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Dry eye disease is a multifactorial disorder of the tears and ocular surface characterized by symptoms of dryness and irritation. Although the pathogenesis of dry eye disease is not fully understood, it is recognized that inflammation has a prominent role in the development and propagation of this debilitating condition. Factors that adversely affect tear film stability and osmolarity can induce ocular surface damage and initiate an inflammatory cascade that generates innate and adaptive immune responses. These immunoinflammatory responses lead to further ocular surface damage and the development of a self-perpetuating inflammatory cycle. Herein, we review the fundamental links between inflammation and dry eye disease and discuss the clinical implications of inflammation in disease management.
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Affiliation(s)
- William Stevenson
- Department of Ophthalmology, Schepens Eye Research Institute and Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
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Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O'Brien T, Rolando M, Tsubota K, Nichols KK. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2011; 52:2050-64. [PMID: 21450919 DOI: 10.1167/iovs.10-6997g] [Citation(s) in RCA: 408] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Gerd Geerling
- Department of Ophthalmology, Heinrich-Heine University, Düsseldorf, Germany
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some patients. A range of treatment options are available but it is unclear which are the most effective. OBJECTIVES To assess the evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY In February 2011 we updated our searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea. DATA COLLECTION AND ANALYSIS Study selection, data extraction, assessment of risk of bias, and analyses were carried out by two independent review authors. MAIN RESULTS Fifty-eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. Only two studies assessed our primary outcome 'quality of life'.Pooled data from physician assessments in three trials provided some evidence that metronidazole was more effective compared to placebo (RR 1.95, 95% CI 1.48 to 2.56). Three trials provided data, based on participants' assessments, illustrating azelaic acid was more effective than placebo (RR 1.52, 95% CI 1.32 to 1.76).Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doses of doxycycline, but there was evidence of less adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54).One study reported that cyclosporine ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea (for all outcomes). AUTHORS' CONCLUSIONS Although the majority of included studies were assessed as being at high or unclear risk of bias there was some evidence to support the effectiveness of topical metronidazole, azelaic acid, and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and cyclosporine 0.5% ophthalmic emulsion for ocular rosacea. Further well-designed, adequately-powered randomised controlled trials are required.
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Affiliation(s)
- Esther J van Zuuren
- Department of Dermatology, Leiden University Medical Center, PO Box 9600, B1-Q, Leiden, Netherlands, 2300 RC
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Bruce Jackson W. Blepharitis: current strategies for diagnosis and management. CANADIAN JOURNAL OF OPHTHALMOLOGY 2008. [DOI: 10.3129/i08-016] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Evidence-based medicine audit as a tool for improving emergency ophthalmology. Eye (Lond) 2007; 23:368-75. [DOI: 10.1038/sj.eye.6703029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:163-78. [PMID: 17508120 DOI: 10.1016/s1542-0124(12)70085-x] [Citation(s) in RCA: 397] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The members of the Management and Therapy Subcommittee assessed current dry eye therapies. Each member wrote a succinct evidence-based review on an assigned aspect of the topic, and the final report was written after review by and with consensus of all subcommittee members and the entire Dry Eye WorkShop membership. In addition to its own review of the literature, the Subcommittee reviewed the Dry Eye Preferred Practice Patterns of the American Academy of Ophthalmology and the International Task Force (ITF) Delphi Panel on Dry Eye. The Subcommittee favored the approach taken by the ITF, whose recommended treatments were based on level of disease severity. the recommendations of the Subcommittee are based on a modification of the ITF severity grading scheme, and suggested treatments were chosen from a menu of therapies for which evidence of therapeutic effect had been presented.
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van Zuuren EJ, Gupta AK, Gover MD, Graber M, Hollis S. Systematic review of rosacea treatments. J Am Acad Dermatol 2007; 56:107-15. [PMID: 17190628 DOI: 10.1016/j.jaad.2006.04.084] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 04/13/2006] [Accepted: 04/15/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rosacea is a common chronic skin and ocular condition. It is unclear which treatments are most effective. We have conducted a Cochrane review of rosacea therapies. This article is a distillation of that work. OBJECTIVE We sought to assess the evidence for the efficacy and safety of rosacea therapies. METHODS Multiple databases were systematically searched. Randomized controlled trials in people with moderate to severe rosacea were included. Study selection, assessment of methodologic quality, data extraction, and analysis were carried out by two independent researchers. RESULTS In all, 29 studies met inclusion criteria. Topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95-12.06). Azelaic acid is more effective than placebo (odds ratio 2.45, 95% confidence interval 1.82-3.28). Firm conclusions could not be drawn about other therapies. LIMITATIONS The quality of the studies was generally poor. CONCLUSIONS There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. More well-designed, randomized controlled trials are required to provide better evidence of the efficacy and safety of other rosacea therapies.
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Affiliation(s)
- Esther J van Zuuren
- Department of Dermatology B1-Q, Leiden University Medical Center, The Netherlands.
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Doughty MJ, Dutton GN. Fusidic acid viscous eyedrops - an evaluation of pharmacodynamics, pharmacokinetics and clinical use for UK optometrists. Ophthalmic Physiol Opt 2006; 26:343-61. [PMID: 16792734 DOI: 10.1111/j.1475-1313.2006.00416.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recent changes in UK law have allowed UK-based optometrists to sell and supply fusidic acid viscous eyedrops, providing it is in the course of their professional activity and in an emergency. Alternatively, the optometrist may access fusidic acid viscous eyedrops, for a named patient, using a written order supplied to a pharmacy. This review provides details of the legal background to these changes, examines the common causes of a bacterial conjunctivitis, examines the mechanism of action of this narrow spectrum antibiotic as a bacteriostatic agent, reviews the susceptibility of common ocular isolates of bacteria to the drug and presents details of the expected pharmacokinetics of the viscous eyedrops. From this perspective, a systematic review is provided of the clinical studies which have investigated the use of fusidic acid viscous eyedrops and their outcome. The indicated use is generally for the treatment of bacterial conjunctivitis and/or blepharoconjunctivitis, especially that caused by Staphylococcus, but not Streptococcus or Haemophilus sp. (more likely associated with concurrent nasopharyngeal infections). The usual regimen for use is twice daily for 5-10 days, depending on severity, and can initially be used more intensively (four times per day). It may also be used for the management of corneal and conjunctival abrasions and foreign body injuries, or some cases of chronic blepharitis.
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Affiliation(s)
- Michael J Doughty
- Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK.
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Abstract
BACKGROUND Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules, and dilated blood vessels. The eyes are often involved. Frequently it can be controlled, but it is not clear which treatments are most effective. OBJECTIVES To assess the evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY We searched the Skin Group Specialised Register (February 2005), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February 2005), EMBASE (1980 to February 2005), BIOSIS (1970 to March 2002) and the Science Citation Index (1988 to February 2005). Reference lists of trials and key review articles were searched. Relevant manufacturers and experts were contacted. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the authors to have seriously flawed methodology were excluded. DATA COLLECTION AND ANALYSIS Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent authors. Disagreements were resolved by discussion and consensus. MAIN RESULTS The evidence provided by twenty-nine included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea were included. Pooled data from two trials involving 174 participants indicated that according to the participants, topical metronidazole is more effective than placebo (odds ratio (OR) 5.96, 95% confidence interval (CI) 2.95 to 12.06). Data pooled from three between-patient trials showed a clear improvement in the azelaic acid group; the rates of treatment success were approximately 70 to 80% versus 50% to 55% (OR 2.45, 95% CI 1.82 to 3.28). A within-patient trial of azelaic cream versus placebo could not be pooled with the other three studies, but also showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians, tetracycline was effective (OR 6.06, 95% CI 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study. AUTHORS' CONCLUSIONS The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. Good RCTs looking at these treatments are urgently needed.
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Affiliation(s)
- E J van Zuuren
- Dermatology department B1-Q, Leiden University Medical Centre, Albinus dreef 2, Leiden, Netherlands, 2333 ZA.
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Voils SA, Evans ME, Lane MT, Schosser RH, Rapp RP. Use of Macrolides and Tetracyclines for Chronic Inflammatory Diseases. Ann Pharmacother 2005; 39:86-94. [PMID: 15562139 DOI: 10.1345/aph.1e282] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions. DATA SOURCES: Searches of MEDLINE (1966–March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. STUDY SELECTION AND DATA EXTRACTION: Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based. DATA SYNTHESIS: Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea. CONCLUSIONS: The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.
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Abstract
BACKGROUND Rosacea is a common skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often also involved. The cause of rosacea is unclear. It is a chronic disease, which can be controlled in most cases with appropriate treatment. Numerous treatments are in use although it is unclear which are best, and which are most appropriate for the different types of rosacea. OBJECTIVES To assess and summarise current evidence for the efficacy and safety of treatments for rosacea. SEARCH STRATEGY We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, March 2002), MEDLINE (from 1966 to March 2002), EMBASE (from 1980 to March 2002), Biosis (from 1970 to March 2002) and the Science Citation Index (from 1988 to March 2002). Reference lists of trials and key review articles were also searched. Relevant manufacturers and experts were contacted. SELECTION CRITERIA Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the reviewers to have seriously flawed methodology were excluded. DATA COLLECTION AND ANALYSIS Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent reviewers. MAIN RESULTS The evidence provided by twenty-two included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea could be included. Pooled data from two trials involving 174 participants indicated that topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95 to 12.06). Data from a between-patient trial (114 patients) and a within-patient trial (33 patients) of azelaic cream versus placebo were not pooled, but both showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians' ratings, tetracycline was effective (odds ratio 6.06, 95% confidence interval 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study. REVIEWER'S CONCLUSIONS The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid cream have a therapeutic effect. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. As many of these treatments are used for rosacea, good RCTs are urgently needed.
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Affiliation(s)
- E J van Zuuren
- Medicines Evaluation Board, Kalvermarkt 53, 2500 BE The Hague, the Netherlands.
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Abstract
PURPOSE To review the basis for the use of oral tetracyclines in ocular rosacea. METHODS Review of the published literature. RESULTS Two prospective, masked, and placebo-controlled studies of oxytetracycline for ocular rosacea demonstrated a modest treatment benefit. Studies performed with tetracycline and doxycycline for ocular rosacea were not placebo controlled, and the optimal drug, dose, and schedule of administration were not evaluated. CONCLUSIONS Available evidence supports a moderate treatment benefit in ocular rosacea for oxytetracycline, a tetracycline derivative not currently available in the United States. The efficacies of doxycycline and tetracycline, including treatment effect, optimal dose, duration of therapy, and side effects when used for ocular rosacea have not been established.
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Affiliation(s)
- Donald U Stone
- Molecular Pathogenesis of Eyer Infection Research Center, Dean A. McGee Eye Institute, Department of Ophthalmology, University of Oklahoma Health Sciences Center, 608 Stanton I. Young Boulevard, Oklahoma City, OK 73104, USA
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Abstract
Rosacea is a multiphasic disease which is associated with flushing, erythrosis, papulopustular rosacea and phymas; each phase is likely to have its own treatment. Flushing is better prevented rather than treated, and its etiology investigated. Beta-blockers, atenolol in particular, are worthy of prophylactic trials examining their efficacy in treating the flushing associated with rosacea. Currently, clonidine is the only drug available for the treatment of flushing. Treatment for erythrosis includes topical and systemic therapies. Metronidazole 1% cream and azelaic acid 20% cream have been reported to reduce the severity score of erythema. The systemic treatment of erythrosis is based on the association of Helicobacter pylori with rosacea. However, this role is still being debated. Eradication of H. pylori can be achieved using a triple therapy regimen lasting 1 to 2 weeks [omeprazole and a combination of two antibacterials (a choice from clarithromycin, metronidazole or amoxicillin)]. Both the flashlamp-pumped long-pulse dye laser and the potassium-titanyl-phosphate laser may be used in the treatment of facial telangiectases. Both systemic and topical remedies may be used to treat the papulopustules of rosacea. Systemic treatment includes metronidazole, doxycycline, minocycline, clarithromycin and isotretinoin, while topical treatment is based on metronidazole cream and gel. The presence of Demodex folliculorum is important in the inflammatory reaction, whether it is pathogenetic or not. Crotamiton 10% cream or permethrin 5% cream may be useful medications for papulopustular rosacea, although they are rarely successful in eradicating D. folliculorum. Oral or topical ivermectin may also be useful in such cases. Ocular involvement is common in patients with cutaneous rosacea and can be treated with orally administered or topical antibacterials. Once rhinophyma starts to be evident, the only way to correct it is by aggressive dermatosurgical procedures. Decortication and various types of lasers can also be used. Associated conditions, such as seborrheic dermatitis and possible contact sensitizations, deserve attention.
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Affiliation(s)
- Alfredo Rebora
- Department of Endocrinological and Metabolic Diseases, Section of Dermatology, University of Genoa, Genoa, Italy.
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Chen PP. Correlation of visual field progression between eyes in patients with open-angle glaucoma. Ophthalmology 2002; 109:2093-9. [PMID: 12414421 DOI: 10.1016/s0161-6420(02)01241-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To investigate the correlation of visual field progression between eyes in patients with chronic forms of open-angle glaucoma (OAG) and to determine risk factors for progression. DESIGN Retrospective observational case series. PARTICIPANTS One hundred fifty-two patients seen between April and November 2000 undergoing bilateral treatment for at least 2 years for OAG and who were followed with standard automated perimetry at the University of Washington Medical Center Eye Clinic. METHODS Visual field progression was defined using criteria modified from Anderson and Advanced Glaucoma Intervention Study (AGIS) scoring. Progression from a normal to an abnormal visual field required abnormality of two of three criteria (glaucoma hemifield test, corrected pattern standard deviation, and total deviation plot abnormality) on at least two consecutive fields. For abnormal visual fields, criteria for progression were modified from Anderson and were based on worsening observed at three adjacent points on the total deviation plot on at least two consecutive fields. Another definition of progression was a change in AGIS score of four or more points. MAIN OUTCOME MEASURES Visual field progression. RESULTS The mean follow-up period was 7.5 +/- 3.6 years. Fifty-four patients (35.5%) showed progression of the more severely affected of the two eyes (worse eye), and 37 patients (24.3%) had progression in the less affected fellow (better) eye. Among these patients, 24 (15.8%) had bilateral progression (44% and 65% of worse and better eyes with progression, respectively). The between-eye correlation for progression was statistically significant (chi-square with Yates' continuity correction; chi = 16.7, P = 0.00004; R = 0.348, P = 0.00001). The Kaplan-Meier estimates at 10 years for progression in the worse eye, the better eye, and both eyes was 44%, 33%, and 21%, respectively. CONCLUSIONS Between-eye correlation of visual field progression in patients with chronic OAG was statistically and clinically significant. Patient-specific factors may play an important role in visual field progression in OAG. Documented progression of visual field loss in one eye may prompt the physician to consider reducing the target intraocular pressure in both eyes.
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Affiliation(s)
- Philip P Chen
- Department of Ophthalmology, University of Washington, Seattle, Washington 98195-6485, USA
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Abstract
Fusidic acid, both systemic and topical, has been used for a wide variety of less common infections. Efficacy for oral fusidic acid has been demonstrated in the treatment of Clostridium difficile colitis and in staphylococcal infections in patients with cystic fibrosis. Topical fusidic acid gel is also effective in bacterial conjunctivitis and other minor external eye infections, and may be effective in reducing bacterial flora in the conjunctival sac prior to eye surgery. Studies suggest a potential role for fusidic acid in neurosurgical prophylaxis, as adjunctive therapy in bacterial endophthalmitis and Legionella pneumonia, and in leprosy. Topical fusidic acid has no effect in the treatment of chlamydial conjunctivitis or the prevention of staphylococcal infections in patients on continuous ambulatory peritoneal dialysis.
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Affiliation(s)
- C Golledge
- Department of Microbiology and Infectious Diseases, Queen Elizabeth 11 Medical Centre, Nedlands, WA, Australia.
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Abstract
In conclusion, when an observation by its nature involves two eyes, as for blindness, statistical analyses should be conducted on individuals rather than eyes and between eye correlation is not a problem. In other circumstances, if information on only one eye per individual is used in the analysis there is a potential "waste" of information leading to less precise estimates of effect and less power. In addition, bias may be introduced into a study if there is non-random selection of the eye for inclusion in the analysis. The use of an overall summary of ocular findings for an individual may result in "wastage" of information in a similar fashion to the use of only one eye per individual. On the other hand, an analysis of individual eyes with no allowance made for between eye correlation may result in falsely narrow confidence intervals around estimates of effect. Between eyes correlation may be assessed empirically using the kappa statistic or similar means. If between eye correlation is substantial, statistical techniques exist which can utilise all available data while allowing for the correlation. In some circumstances a powerful design may be to use the fellow eye as a "control". Two conclusions may be drawn from this review of analytical approaches to the analysis of clinical data in the BJO. Firstly, the analytical approaches employed in many studies fail to use all the data available. In other words the analysis is less than "optimal". Secondly, in a proportion of studies, inappropriate statistical methods are used which may lead the investigator to draw inappropriate conclusions. In other words, the analysis is invalid. Ophthalmic data, by their very nature, present particular statistical challenges. We emphasise the need to involve appropriate statistical expertise in the design and analysis of ophthalmic studies.
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Affiliation(s)
- I E Murdoch
- Department of Preventive Ophthalmology, Institute of Ophthalmology, London
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