Dry Eye Syndrome in Postmenopausal Women

[Guest guest]

Hi, I found this letter to the editor and a reply from him/her in the

Feb. 6, 2002, issue of the Journal of the American Medical Association

(JAMA). Hope it helps someone!

Matija

Dry Eye Syndrome in Postmenopausal Women

To the Editor: Dr Schaumberg and colleagues1 concluded that women who

receive hormone replacement therapy (HRT), especially with unopposed

estrogen therapy, have an increased risk of dry eye syndrome.

Although they found no medical conditions to have a confounding

impact, they did not consider rosacea in the list of confounding

conditions.

Clinically significant rosacea occurs in approximately 30% of

menopausal women.2 The diagnosis of rosacea is based on the finding

of persistent erythema, prominent telangiectases, and papulopustules

of the cheeks, chin, and forehead. Easy flushing or blushing due to

physical exertion or consumption of hot beverages is also

characteristic. Noticeably lacking are the comedones that

characterize acne vulgaris. The authors' failure to include rosacea

as a confounding condition is significant because of the coexistence

of this cutaneous condition with ocular rosacea. Ocular rosacea is a

common cause of dry eye or keratoconjunctivitis sicca.3 While the

incidence of ocular rosacea is not known, it may be present in as

many as 58% of patients with rosacea and has been suggested to be

present in up to 75% of perimenopausal women with facial rosacea.2, 4

Another study found all patients with cutaneous rosacea to have some

degree of ocular involvement.5 Common symptoms of ocular rosacea

include irritation and dryness, the same 2 symptoms assessed by

Schaumberg et al.

The authors conclude that estrogen therapy may impair meibomian gland

function. Meibomian gland dysfunction can be a common finding in

patients with rosacea.5 A question still to be answered is whether

estrogen therapy contributes to the etiology of cutaneous or ocular

rosacea.

Given the high incidence of both cutaneous and ocular rosacea in

postmenopausal women, this disease process should be considered as a

possible confounding factor in any study of dry eye syndrome. In

patients with ocular rosacea, a course of oral tetracycline or

doxycycline can significantly improve their ophthalmic symptoms.3, 5

M. , MD

Jack L. Lesher, Jr, MD

Loretta S. , MD

Section of Dermatology

The Medical College of Georgia

Augusta

1. Schaumberg DA, Buring JE, Sullivan DA, Dana MR. Hormone

replacement therapy and dry eye syndrome. JAMA. 2001;286:2114-2119.

ABSTRACT | FULL TEXT | PDF | MEDLINE

2. Kligman AM. Ocular rosacea: current concepts and therapy

[editorial]. Arch Dermatol. 1997;133:89-90. MEDLINE

3. Lemp MA, Mahmood MA, Weiler HH. Association of rosacea and

keratoconjunctivitis sicca. Arch Ophthalmol. 1984;102:556-557.

MEDLINE

4. Starr PA. Oculocutaneous aspects of rosacea. Proc R Soc Med.

1969;62:9-11. MEDLINE

5. Quarterman MJ, DW, Abele DC, Lesher JL Jr, Hull DS,

LS. Ocular rosacea: signs, symptoms, and tear studies before and

after treatment with doxycycline. Arch Dermatol. 1997;133:49-54.

MEDLINE

In Reply: We agree with Dr and colleagues that ocular

rosacea is a frequent and important, and perhaps underappreciated,

cause of dry eye syndrome, particularly in certain ethnic groups.

However, the proportion of dry eye cases attributable to this

disorder is only speculative and solid epidemiological data on the

prevalence of rosacea are lacking.1 The 30% prevalence of rosacea

among postmenopausal women cited by et al is much higher

than other estimates, which are in the range of 3% to 5%,2 and is

derived from the clinical observations of a single dermatologist.1 In

any event, even if rosacea were common, this would not be sufficient

for rosacea to have confounded the association we observed between

HRT and dry eye syndrome. For rosacea to confound the relationship,

postmenopausal women with rosacea would have had to have been more

likely to have received HRT, and specifically more likely to have

taken estrogen alone, as we found a higher risk of dry eye syndrome

among women using estrogen only than among those using estrogen plus

progesterone/progestin. However, we are not aware of any evidence to

suggest that women with ocular rosacea are more likely to use HRT in

general or, more specifically, to use estrogen alone compared with

women without this condition. It is consequently unlikely, from a

statistical point of view, that ocular rosacea is an important

confounder of the increased risk of dry eye syndrome we observed

among women who received HRT. More at issue, perhaps, is whether the

effect of HRT on dry eye syndrome, if causal, is differential with

regard to certain subgroups of patients with dry eye syndrome, such

as those due to ocular rosacea. Since one potential mechanism through

which estrogen might influence the development of dry eye is via

alterations of the secretions of the meibomian glands,3 which are

also affected in ocular rosacea, we think that this is an important

issue that will require further study.

Debra A. Schaumberg, ScD, MPH

M. Reza Dana, MD, MPH

Division of Preventive Medicine

Brigham and Women's Hospital

Boston, Mass

1. Kligman AM. Ocular rosacea: current concepts and therapy

[editorial]. Arch Dermatol. 1997;133:89-90. MEDLINE

2. Plewig G, Kligman AM. cea. In: Acne and cea. 2nd ed. New

York, NY: Springer-Verlag; 1995.

3. Suzuki T, Schaumberg DA, Sullivan BD, et al. Do estrogens and

progesterone play a role in the dry eye of Sjogren's syndrome? Ann N

Y Acad Sci. In press.

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Letters Section Editor: J. Lurie, MD, PhD, Senior Editor.