- Email: [email protected]
The Effect of Doxycycline on Ocular Rosacea
434
AMERICAN JOURNAL OF OPHTHALMOLOGY
into the ciliary body. Four months later, a biopsy specimen of right parotid gland showed metastatic fibrous histiocytoma (Fig. 2). The patient underwent right parotidectomy and right radical neck dissection. Ten months after surgery, multiple pulmonary nodules were found on a chest x-ray. The patient declined further treatment and died within a year. Two of the malignant fibrous histiocytomas of the conjunctiva described in the literature occurred at the corneoscleral limbus and were locally invasive. 1.2 One extended into the ciliary body.' The third case was reported at the Armed Forces Institute of Pathology Alumni meeting in June 1985 by Jacob Pe'er and was cited in a report by Lahoud, Brownstein, and Laflamme." This pleomorphic fibrous histiocytoma was treated by orbital exenteration when it recurred after primary excision. The patient never developed signs of metastatic disease. Our case illustrates what has been assumed to be the biologic potential of malignant fibrous histiocytoma of the conjunctiva. These tumors have the capacity to metastasize and cause death. Malignant fibrous histiocytomas of the conjunctiva should be treated promptly by complete surgical excision.
References 1. Delgado-Partida, P., and Rodriguez-Trujillo, F.: Fibrosarcoma (malignant fibroxanthoma) involving conjunctiva and ciliary body. Am. J. Ophthalmol. 74:479, 1972. 2. Urdiales-Viedrna, M., Moreno-Prieto, M., and Martos-Padilla, S.: Pleomorphic fibrous histiocytoma of the corneoscleral limbus. Am. J. Ophthalmol. 95:560, 1983. 3. Lahoud, S., Brownstein, S., and Laflamme, M. Y:: Fibrous histiocytoma of the corneosclerallimbus and conjunctiva. Am. J. Ophthalmol. 106:579, 1988.
The Effect of RO$acea
Doxycycline
on
Ocular
Joseph Frucht-Pery, M.D., Arturo S. Chayet M.D., Sandy T. Feldman, M.D., Steven Lin, and Stuart I. Brown, M.D. Department of Ophthalmology, University of Ca~i fornia at San Diego. This study was supported
In
April, 1989
part by a Foreign Fellowship grant from Research to Prevent Blindness, Inc.
Inquiries to Stuart I. Brown, M.D., Department of Ophthalmology, University of California at San Diego
(T-014), La lalla, CA 92093.
Rosacea is a common skin disease of unknown origin that affects the cheek, nose, and forehead. Ocular manifestations have been well described, 1-3 and only tetracycline has been reported to be effective in their treatment. We report the effect of doxycycline, a semisynthetic tetracycline (2, 6 deoxy-5-hydroxytetracycline), on ocular rosacea. Sixteen consecutive patients with ocular rosacea, eight men and eight women aged 29 to 75 years, were treated with oral doxycycline and followed up for 16 to 25 months. Of our 16 patients, 13 had not been treated previously for rosacea. Three patients had been treated previously with oral tetracycline. It was discontinued after gastrointestinal complications in two patients and the third patient had a short remission and a recurrence of symptoms. Rosacea was diagnosed by the presence of at least two of the following: telangiectasias of the nose or face, hypertrophic sebaceous glands, papules, pustules, or erythema of the face. Treatment was given for the ocular symptoms of foreign-body sensation, burning and tearing, recurrent chalazions, blepharitis, and peripheral corneal infiltrations. The patient was considered improved when both signs and symptoms of the disorder resolved. Each patient was given 100 mg of doxycycline once a day for a minimum of one month. As with tetracycline, improvement was not noted until after four days of treatment. After one month the dose was tapered to 50 mg once a day for at least one month, then the same dose every other day for one month, and finally stopped. The dosage reduction was only maintained if the patient remained asymptomatic. If no improvement was noted, doxycycline was discontinued and 250 mg of tetracycline hydrochloride four times a day was instituted. Of 16 patients, 14 had symptomatic improvement during the first three weeks. The two remaining patients who did not improve after six weeks were given tetracycline. One had immediate relief of symptoms while the other remained symptomatic and the tetracycline was stopped. Of the 14 patients who had symptomatic improvement, eight remained on various doses of doxycycline throughout the study period. In four patients the dose was tapered and in three of them discontinued without the recurrence of symptoms. However, in the
Letters to the Journal
Vol. 107, No.4
fourth patient, 100 mg of doxycycline once a day was resumed successfully upon recurrence of symptoms after three months off medication. The treatment of two of the 14 patients who were asymptomatic on treatment with doxycycline was eventually changed. The first developed a peripheral corneal infiltrate and was treated with 250 mg of tetracycline four times a day. The second had a phototoxic skin reaction after four months and was treated with 50 mg of minocycline twice a day. Both patients remained asymptomatic during the follow-up period. Our study indicated that a single dose of doxycycline may be an effective treatment for ocular rosacea. Previous experience with tetracycline in ocular rosacea showed similar results.! The only complication related to the use of doxycycline was one episode of photosensitivity. In this patient, minocycline was given because it has been associated with fewer episodes of photosensitivity. 3 In contrast to previous experience with tetracycline," no gastrointestinal complications such as diarrhea or dyspepsia developed during treatment with doxycycline. Doxycycline is structurally similar to tetracycline hydrochloride; however, doxycycline is absorbed better and affected less by the food in the gastrointestinal tract compared to tetracycline.' The serum half-life of doxycycline is double that of tetracycline and, therefore, a smaller dose is required to be therapeutic. In contrast to tetracycline, doxycycline does not have an anabolic effect, is not excreted by the renal route, and can be used in patients with severe renal disease." Finally, because doxycycline is given once a day without regard to meals (except eliminating milk products at the time of drug digestion), patient compliance may be high. We recommend that doxycycline be used in patients with ocular rosacea and that tetracycline remain an alternative treatment if doxycycline fails.
435
4. Neu, H. c.: A symposium on the tetracyclines. A major appraisal. Bull. N.Y. Acad. Med. 54:141, 1978.
Pediatric Moisture Chambers Mary A. O'Hara, M.D., and Joseph H. Calhoun, M.D. Department of Pediatric Ophthalmology, Wills Eye Hospital. Supported in part by a grant from Fight For Sight, Inc., of New York to the Fight For Sight Children's Eye Center, Wills Eye Hospital, Philadelphia, Pennsylvania.
Inquiries to Mary A. O'Hara, M.D., Derartment of Pediatric Ophthalmology, Wills Eye Hospita , Ninth and Walnut Sts., Philadelphia, PA 19107.
Treatment of exposure keratopathy, a frustrating problem with potentially devastating consequences, varies with each patient.' When lubrication agents are insufficient and tarsorrhaphy is not suitable, other modes of management must be explored. Moisture chambers.t" designed to slow the rate of tear evaporation, have proven successful for many adult patients. Their use in children has been hampered by many factors. Products too large for children, intolerance to goggles, and concerns about occlusion amblyopia have hampered the use of moisture chambers in the pediatric age group. We found that the various transparent coverings from packages of disposable medical supplies can be used as miniature bandage bubbles." Since these packages come in different sizes (Fig. 1), they are particularly suited for
References 1. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1965, p. 537. 2. Jenkins, M. S., Brown, S. I., Lempert, S. L., and Weinberg, R. J.: Ocular rosacea. Am. J. Ophthalmol. 88:618, 1979. 3. Lempert, S. L., Jenkins, M. S., and Brown, S. I.: Chalazia and rosacea. Arch. Ophthalmol. 97:1652, 1979.
Fig. 1 (O'Hara and Calhoun). Samples of different sizes of bubble packages.
AMERICAN JOURNAL OF OPHTHALMOLOGY
into the ciliary body. Four months later, a biopsy specimen of right parotid gland showed metastatic fibrous histiocytoma (Fig. 2). The patient underwent right parotidectomy and right radical neck dissection. Ten months after surgery, multiple pulmonary nodules were found on a chest x-ray. The patient declined further treatment and died within a year. Two of the malignant fibrous histiocytomas of the conjunctiva described in the literature occurred at the corneoscleral limbus and were locally invasive. 1.2 One extended into the ciliary body.' The third case was reported at the Armed Forces Institute of Pathology Alumni meeting in June 1985 by Jacob Pe'er and was cited in a report by Lahoud, Brownstein, and Laflamme." This pleomorphic fibrous histiocytoma was treated by orbital exenteration when it recurred after primary excision. The patient never developed signs of metastatic disease. Our case illustrates what has been assumed to be the biologic potential of malignant fibrous histiocytoma of the conjunctiva. These tumors have the capacity to metastasize and cause death. Malignant fibrous histiocytomas of the conjunctiva should be treated promptly by complete surgical excision.
References 1. Delgado-Partida, P., and Rodriguez-Trujillo, F.: Fibrosarcoma (malignant fibroxanthoma) involving conjunctiva and ciliary body. Am. J. Ophthalmol. 74:479, 1972. 2. Urdiales-Viedrna, M., Moreno-Prieto, M., and Martos-Padilla, S.: Pleomorphic fibrous histiocytoma of the corneoscleral limbus. Am. J. Ophthalmol. 95:560, 1983. 3. Lahoud, S., Brownstein, S., and Laflamme, M. Y:: Fibrous histiocytoma of the corneosclerallimbus and conjunctiva. Am. J. Ophthalmol. 106:579, 1988.
The Effect of RO$acea
Doxycycline
on
Ocular
Joseph Frucht-Pery, M.D., Arturo S. Chayet M.D., Sandy T. Feldman, M.D., Steven Lin, and Stuart I. Brown, M.D. Department of Ophthalmology, University of Ca~i fornia at San Diego. This study was supported
In
April, 1989
part by a Foreign Fellowship grant from Research to Prevent Blindness, Inc.
Inquiries to Stuart I. Brown, M.D., Department of Ophthalmology, University of California at San Diego
(T-014), La lalla, CA 92093.
Rosacea is a common skin disease of unknown origin that affects the cheek, nose, and forehead. Ocular manifestations have been well described, 1-3 and only tetracycline has been reported to be effective in their treatment. We report the effect of doxycycline, a semisynthetic tetracycline (2, 6 deoxy-5-hydroxytetracycline), on ocular rosacea. Sixteen consecutive patients with ocular rosacea, eight men and eight women aged 29 to 75 years, were treated with oral doxycycline and followed up for 16 to 25 months. Of our 16 patients, 13 had not been treated previously for rosacea. Three patients had been treated previously with oral tetracycline. It was discontinued after gastrointestinal complications in two patients and the third patient had a short remission and a recurrence of symptoms. Rosacea was diagnosed by the presence of at least two of the following: telangiectasias of the nose or face, hypertrophic sebaceous glands, papules, pustules, or erythema of the face. Treatment was given for the ocular symptoms of foreign-body sensation, burning and tearing, recurrent chalazions, blepharitis, and peripheral corneal infiltrations. The patient was considered improved when both signs and symptoms of the disorder resolved. Each patient was given 100 mg of doxycycline once a day for a minimum of one month. As with tetracycline, improvement was not noted until after four days of treatment. After one month the dose was tapered to 50 mg once a day for at least one month, then the same dose every other day for one month, and finally stopped. The dosage reduction was only maintained if the patient remained asymptomatic. If no improvement was noted, doxycycline was discontinued and 250 mg of tetracycline hydrochloride four times a day was instituted. Of 16 patients, 14 had symptomatic improvement during the first three weeks. The two remaining patients who did not improve after six weeks were given tetracycline. One had immediate relief of symptoms while the other remained symptomatic and the tetracycline was stopped. Of the 14 patients who had symptomatic improvement, eight remained on various doses of doxycycline throughout the study period. In four patients the dose was tapered and in three of them discontinued without the recurrence of symptoms. However, in the
Letters to the Journal
Vol. 107, No.4
fourth patient, 100 mg of doxycycline once a day was resumed successfully upon recurrence of symptoms after three months off medication. The treatment of two of the 14 patients who were asymptomatic on treatment with doxycycline was eventually changed. The first developed a peripheral corneal infiltrate and was treated with 250 mg of tetracycline four times a day. The second had a phototoxic skin reaction after four months and was treated with 50 mg of minocycline twice a day. Both patients remained asymptomatic during the follow-up period. Our study indicated that a single dose of doxycycline may be an effective treatment for ocular rosacea. Previous experience with tetracycline in ocular rosacea showed similar results.! The only complication related to the use of doxycycline was one episode of photosensitivity. In this patient, minocycline was given because it has been associated with fewer episodes of photosensitivity. 3 In contrast to previous experience with tetracycline," no gastrointestinal complications such as diarrhea or dyspepsia developed during treatment with doxycycline. Doxycycline is structurally similar to tetracycline hydrochloride; however, doxycycline is absorbed better and affected less by the food in the gastrointestinal tract compared to tetracycline.' The serum half-life of doxycycline is double that of tetracycline and, therefore, a smaller dose is required to be therapeutic. In contrast to tetracycline, doxycycline does not have an anabolic effect, is not excreted by the renal route, and can be used in patients with severe renal disease." Finally, because doxycycline is given once a day without regard to meals (except eliminating milk products at the time of drug digestion), patient compliance may be high. We recommend that doxycycline be used in patients with ocular rosacea and that tetracycline remain an alternative treatment if doxycycline fails.
435
4. Neu, H. c.: A symposium on the tetracyclines. A major appraisal. Bull. N.Y. Acad. Med. 54:141, 1978.
Pediatric Moisture Chambers Mary A. O'Hara, M.D., and Joseph H. Calhoun, M.D. Department of Pediatric Ophthalmology, Wills Eye Hospital. Supported in part by a grant from Fight For Sight, Inc., of New York to the Fight For Sight Children's Eye Center, Wills Eye Hospital, Philadelphia, Pennsylvania.
Inquiries to Mary A. O'Hara, M.D., Derartment of Pediatric Ophthalmology, Wills Eye Hospita , Ninth and Walnut Sts., Philadelphia, PA 19107.
Treatment of exposure keratopathy, a frustrating problem with potentially devastating consequences, varies with each patient.' When lubrication agents are insufficient and tarsorrhaphy is not suitable, other modes of management must be explored. Moisture chambers.t" designed to slow the rate of tear evaporation, have proven successful for many adult patients. Their use in children has been hampered by many factors. Products too large for children, intolerance to goggles, and concerns about occlusion amblyopia have hampered the use of moisture chambers in the pediatric age group. We found that the various transparent coverings from packages of disposable medical supplies can be used as miniature bandage bubbles." Since these packages come in different sizes (Fig. 1), they are particularly suited for
References 1. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1965, p. 537. 2. Jenkins, M. S., Brown, S. I., Lempert, S. L., and Weinberg, R. J.: Ocular rosacea. Am. J. Ophthalmol. 88:618, 1979. 3. Lempert, S. L., Jenkins, M. S., and Brown, S. I.: Chalazia and rosacea. Arch. Ophthalmol. 97:1652, 1979.
Fig. 1 (O'Hara and Calhoun). Samples of different sizes of bubble packages.