1. COMPARISON OF MMP-9 AND IL-1α Tear levels in patients with active ocular rosacea before and after oral doxycycline or azithromycin THERAPY
Lorena Lam-Franco MD, Beatriz E. Patiño-Ramírez MD, Yocan Perfecto MSc., Alejandro Rodríguez-García MD.
Instituto de Oftalmología y Ciencias Visuales. Programa Multi-céntrico de residencia en Oftalmología. Escuela Nacional de Medicina.
Tecnológico de Monterrey. México.

2. Financial disclosure
The authors have no financial disclosures that would be a potential conflict of interest with this presentation.

3. OCULAR ROSACEA (OcR)
Affects more than half patients with cutaneous disease
(reported up to 58%).
Chronic inflammatory ocular surface disease characterized by vascular hyperreactivity and altered immune system responses, including the upregulation of different pro-inflammatory cytokines.
Rodríguez-García A. “Ocular Rosacea: Recent Advances in Pathogenesis and Therapy.” In: Advances in Dermatology Research. James P. Vega (editor). Nova Biomedical Science Publishers, Inc Hauppauge, N.Y. USA. Chapter 15. Pp ISBN:

4. purpose
To determine the tear levels of matrix metalloproteinase-9 (MMP- 9) and interleukin-1 alpha (IL-1α) in patients with active OcR and compared them to normal controls.
To compare the tear levels of both cytokines after treatment with oral doxycycline or azithromycin.

5. METHODS Case-control study.
Eligibility: patients with active OcR seen at Institute of Ophthalmology and Visual Sciences. Zambrano Hellion Medical Center, from July 2014 to January 2015.
We included patients with active OcR seen at our Center in a period of 6 months.

6. Inclusion criteria Exclusion criteria
Diagnosis based on the National Rosacea Society Expert Committee criteria
Patients older than 18yo
No previous antibiotic therapy
Signed informed consent
Contact lens wearer
Previous ocular surgery
Ocular surface disease or uveitis
Previous topical drugs
Contraindication to receive any of the medications used in the study
Wilkin J, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002; 46:584-7.

7. Tear samples were obtained at first visit and after 4 weeks.
Study sample:
23 OcR patients
18 healthy controls
Experimental groups:
Group A: Doxycycline 200mg/day for 4 weeks.
Group B: Azithromycin 500mg/day, three days a week for 4 weeks.
Tear samples were obtained at first visit and after 4 weeks.
MMP-9 and IL-1 α were measured by ELISA (quantikine® R&D systems, Minneapolis, MN).

8. Statistical analysis
Data distribution was not normal (Kolmogorov-Smirnov test).
Kruskal-Wallis or Mann-Whitney non parametric tests.
p value <0.05 was considered statistically significant.

9. BASELINE AGE AND GENDER DISTRIBUTION
OcR
(n=23)
Controls
(n=18)
Mean age
(Range)
61.78
(34-82)
30.5
(26-40)
Men (%)
6 (26.0)
4 (22.0)
Women (%)
17 (74.0)
14 (78.0)

10. Number of subjects per treatment group.
Treatment groups
Number of subjects per treatment group.
Group A
Doxycycline
Group B
Azithromycin
Before treatment 12 11
After treatment 10

11. IL1-α TEAR LEVELS BEFORE TREATMENT
IL1-α levels
OcR patients (mean 37.9pg/ml)
Healthy controls (mean 0.001pg/ml)
IL1-α levels (mean 37.9pg/ml) was significantly higher in OcR patients compared to healthy controls (mean 0.001pg/ml) (P<0.001).

12. MMP-9 tear levels before treatment
MMP-9 levels
OcR patients (mean 26.7ng/ml)
Control group (mean 0.2ng/ml)
MMP-9 levels in OcR patients before treatment (mean 26.7ng/ml) were significantly higher compared with the control group (mean 0.2ng/ml) (P<0.001).

13. IL1-α TEAR LEVELS AFTER DOXYCYCLINE THERAPY
IL-1α levels
Pre treatment (mean 29.6pg/ml)
Post treatment (mean 46.7pg/ml)
IL-1α levels after treatment with 4 weeks of treatment with doxycycline were higher than baseline levels (pre treatment mean 29.6pg/ml, post treatment mean 46.7pg/ml), although not statistically significant (P=0.392).

14. Post doxycycline treatment, IL-1α levels were significantly different compared with controls (P=0.001).

15. MMP-9 tear levels after doxycycline THERAPY
MMP-9 levels
Pre treatment (mean 9.4ng/ml)
Post treatment (mean 55.2ng/ml)
After treatment MMP-9 levels were higher than baseline levels (pre treatment mean 9.4ng/ml, post treatment mean 55.2ng/ml) (P=0.217).
Presence of outlier which had an initial concentration of 129.6ng/ml and 876.6ng/ml after treatment.

16. MMP-9 post treatment levels were still significantly higher than healthy controls (P=0.013).
Analizando solamente las mediciones cuantitativas de la IL1-α y MMP-9, la doxiciclina parece no tener efecto benéfico sobre las mismas, ya que los valores permanecen significativamente mayores que los controles en ambos casos al terminar un mes de tratamiento.

17. IL1-α TEAR LEVELS AFTER AZITHROMYCIN THERAPY
IL-1α levels
Pre treatment (mean 47.0pg/ml)
Post treatment (mean 23.5pg/ml)
IL-1α post treatment levels were significantly lower than initial levels (pre treatment mean 47.0pg/ml, post treatment mean 23.5pg/ml) (P=0.024).

18. There was no statistical difference between levels of IL-1 α after azithromycin treatment and controls (P=0.084).

19. MMP-9 tear levels after azithromycin THERAPY
MMP-9 levels
Pre treatment (mean 45.3ng/ml)
Post treatment (mean 23.3ng/ml)
MMP-9 post treatment levels were lower compared with baseline levels (pre treatment mean 45.3ng/ml, post treatment mean 23.3ng/ml), although not statistically significant (P=0.085).

20. Compared with controls, post azithromycin treatment levels were still significantly higher (P=0.009).

21. Discussion
In accordance to previous reports, we found a higher concentration of IL-1α and MMP-9 in tears of active OcR patients when compared to healthy controls, suggesting their potential role in the inflammatory process on the ocular surface.
Matta et al., found lower MMP-8 tear levels in OcR patients after treatment with doxycycline.
To the best of our knowledge, this is the first study that analyzed IL-1α and MMP-9 tear levels in OcR before and after treatment with two different oral antibiotics (doxycycline and azithromycin).
REFERENCIA
Matta M, et al. Tear fluid levels of MMP-8 are elevated in ocular rosacea--treatment effect of oral doxycycline.Graefes Arch Clin Exp Ophthalmol. 2006 Aug;244(8):

22. Doxycycline did not show a significant lowering effect on IL-1α and MMP-9 tear levels after 4 weeks of treatment.
On the contrary, in the azithromycin group, both IL-1α and MMP-9 tear levels were lower after 4 weeks of treatment, being statistically significant only for IL-1α with levels similar to healthy controls.

23. Conclusions
Finding increased tear levels of IL-1α and MMP-9 in patients with active OcR compared to controls suggests that these pro- inflammatory cytokines may play a role in the pathogenesis of the ocular disease.
We were not able to show a lowering effect of Doxycycline on both, IL-1α and MMP-9 tear levels after 4 weeks of treatment.
On the other hand both cytokines, but particularly IL-1a showed a lower tear level after azithromycin therapy.
After analyzing clinical response, patients with higher cytokine levels after treatment did not improve symptoms. (Data not shown)
After clinical correlation analysis

24. Thank YOU!