Aetiology

Ocular manifestation of rosacea, a chronic relapsing inflammatory condition of the skin predominantly affecting the centrofacial region (cheeks, nose, and forehead). Although rosacea was previously classified based on four discrete subtypes, it is now recognised that there is significant overlap in clinical manifestations between subtypes

Predisposing factors

Rosacea is a common disorder (prevalence in the general population 5.5%) with a peak incidence between the fourth and sixth decades of life. Females are more likely to be affected than males, but the disease can often be more severe in males. Reportedly more common in fair-skinned people of Celtic and Northern European origin

Ocular manifestations occur in 58-72% of patients with rosacea, affecting both sexes equally

Ocular rosacea is most often diagnosed when cutaneous signs and symptoms are present, but it may occur prior to skin involvement (in approx. 20% of cases)

There is no correlation between the severity of the ocular disease and the severity of the cutaneous disease

Note: rosacea was previously called acne rosacea, a misleading term since the condition is unrelated to acne vulgaris

Symptoms of ocular rosacea

Ocular symptoms

• discomfort, irritation, itching, foreign body sensation
• ocular dryness
• photophobia
• blurred vision (if cornea involved)

Cutaneous symptoms

• frequent facial flushing (exacerbated by trigger factors) progressing to persistent erythema

Psychological problems including embarrassment, loss of confidence and depression

Signs of ocular rosacea

Ocular signs: lids and tear film

• hyperaemic thickened lids
• telangiectasia of the lid margins
• chronic posterior marginal blepharitis
• recurrent acute lid infections (chalazion, hordeolum)
• tear film deficiency and/or instability

Ocular signs: cornea (up to 30% of rosacea patients)

• punctate staining (fluorescein) of lower third of cornea (usually)
• peripheral vascularisation of inferior cornea
• subepithelial infiltrates around corneal vessels
• sterile ulceration
• corneal thinning (may lead to perforation)
• scarring secondary to corneal involvement
• sclerokeratitis

The Global ROSacea COnsensus Panel (ROSCO) defined a minimum combination of ocular features for a diagnosis of ocular rosacea; lid margin telangiectasia and inter-palpebral injection, or corneal abnormalities, or scleral inflammation

Cutaneous signs

• chronic hyperaemia of nose, central forehead and upper cheeks
• telangiectasia of facial blood vessels (permanently distended blood vessels with a spidery appearance)
• papules, pustules and hypertrophy of sebaceous glands
• rhinophyma (bullous nose) in severe cases

Differential diagnosis

Tear deficiency
Interstitial keratitis
Infectious keratitis
Other causes of chronic blepharitis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

• Advice on avoiding the causes of exacerbations (including facial flushing) if these have been identified by the patient; can include spicy foods, alcohol, sunlight, heat, cosmetics and soaps

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

• Omega 3 fatty acid supplementation

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

• Management of associated conditions such as chalazion, hordeolum (stye), posterior marginal blepharitis and tear deficiency or instability (see Clinical Management Guidelines on Blepharitis, Chalazion, Hordeolum, Dry Eye)
• Intense Pulsed Light (IPL) therapy has been recommended for the management of Ocular Rosacea associated with Dry Eye Disease. However, a 2020 Cochrane Review found a lack of evidence as to the effectiveness and safety of this treatment modality

• Ocular lubricants for tear deficiency/instability related symptoms 
  NB: Patients on long-term medication may develop sensitivity reactions which may be to active ingredients or to preservative systems (see Clinical Management Guideline on Conjunctivitis Medicamentosa). They should be switched to unpreserved preparations

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

• Oral antibiotic therapy: doxycycline 40mg modified release once daily for up to 6 weeks (contraindicated in pregnancy and in children under 12 years; various adverse effects have been reported)
• Where tetracyclines are contraindicated, consider prescribing oral
  erythromycin or azithromycin
  
  NB: optometrist prescription of oral antibiotic not recommended unless diagnosis of (cutaneous) rosacea confirmed by dermatologist or GP 

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Management category

B2: alleviation/palliation; no referral, but consider co-management with dermatologist or GP
A3: urgent referral to an ophthalmologist if keratitis is severe

Possible management by ophthalmologist

Topical ciclosporin (unlicensed indication)
Topical steroid for management of severe corneal disease
Topical Ivermectin cream to eyelid skin
Management of corneal perforation: tissue adhesive, lamellar keratoplasty, penetrating keratoplasty
Restoration of vision lost through corneal disease: penetrating keratoplasty (but high risk of rejection)

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Bhargava R, Chandra M, Bansal U, Singh D, Ranjan S, Sharma S. A randomized controlled trial of omega 3 fatty acids in rosacea patients with dry eye symptoms. Curr Eye Res. 2016;41(10):1274-1280

Cote S, Zhang AC, Ahmadzai V, Maleken A, Li C, Oppedisano J, Nair K, Busija L, Downie LE. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD013559

Gallo RL, Granstein RD, Kang S, Mannis M, Steinhoff M, Tan J, Thiboutot D. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148-155

Gether L, Overgaard LK, Egeberg A, Thyssen JP Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018;179(2):282-289

Redd TK, Seitzman GD. Ocular rosacea. Curr Opin Ophthalmol. 2020;31(6):503-507

Sagaser S, Butterfield R, Kosiorek H, Kusne Y, Maldonado J, Fautsch MP, Patel D, Shen JF. Effects of intense pulsed light on tear film TGF-β and microbiome in ocular rosacea with dry eye. Clin Ophthalmol. 2021;15:323-330

Schaller M, Almeida LMC, Bewley A, Cribier B, Del Rosso J, Dlova NC et al. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. Br J Dermatol. 2020;182(5):1269-1276.

Sobolewska B, Doycheva D, Deuter C, Pfeffer I, Schaller M, Zierhut M. Treatment of ocular rosacea with once-daily low-dose doxycycline. Cornea. 2014;33(3):257-60

Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed. J Am Acad Dermatol. 2013;69(6 Suppl 1):S36-41

Wladis EJ, Adam AP. Treatment of ocular rosacea. Surv Ophthalmol. 2018;63(3):340-346

Wladis EJ, Bradley EA, Bilyk JR, Yen MT, Mawn LA Oral antibiotics for meibomian gland-related ocular surface disease: A report by the American Academy of Ophthalmology. Ophthalmology. 2016; 123(3):492-6

van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015;4:CD003262

Ocular rosacea
Version 11
Date of search 23.04.22
Date of revision 05.09.22
Date of publication 13.09.22
Date for review 22.04.24
© College of Optometrists