Ocular rosacea

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Ocular manifestations of rosacea, a chronic relapsing skin disease of unknown aetiology which often requires long-term management

Predisposing factors

Rosacea is a common disorder (prevalence up to 10%) with a peak incidence between the fourth and sixth decades of life. It affects females twice as often as 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

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

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 (permanent 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

Non pharmacological
  • 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)
Pharmacological
  • 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) 
    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

Ghanem VC, Mehra N, Wong S, Mannis MJ. The prevalence of ocular signs in acne rosacea: comparing patients from ophthalmology and dermatology clinics. Cornea. 2003;22(3):230-3

Schaller M, Almeida LM, Bewley A, Cribier B, Dlova NC, Kautz G, Mannis M, Oon HH, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren E, Tan J. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol. 2017;176(2):465-471

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

Stone DU, Chodosh J. Oral tetracyclines for ocular rosacea: an evidence-based review of the literature. Cornea. 2004;23(1):106-9

Tan J, Almeida LM, Bewley A, Cribier B, Dlova NC, Gallo R, Kautz G, Mannis M, Oon HH, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren EJ, Schaller M. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol.
2017;176(2):431-438

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

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

Lay summary

Rosacea is a common skin disorder, affecting up to one in ten people between the ages of 40 and 60, that can also affect the eye. It causes redness of the nose, forehead and upper cheeks, along with inflammation of the oil glands of the skin. Around a half of rosacea patients have eye involvement, with symptoms of discomfort, dryness and light sensitivity. The optometrist may find inflammation of the eyelids and abnormalities of the tear film (the thin layer of tears covering the surface of the eye) which cause patchy drying of the eye surface. This can cause inflammation of the cornea (the clear window at the front of the eye) with thinning, ulceration, ingrowth of abnormal blood vessels and scarring, all of which can lead to reduced vision.

Dietary advice may help, as may attention to the inflammation of the eyelids. Artificial tears and lubricating ointments may relieve discomfort. An antibiotic given by mouth, usually a drug from the tetracycline family, can improve the condition of both the skin and the eyes. If the condition does not respond to simple measures such as these, the optometrist will refer the patient to the ophthalmologist, who may consider prescribing other drugs and may possibly recommend surgery.

Ocular rosacea
Version 9
Date of search 14.02.18
Date of revision 21.08.18
Date of publication 16.10.18
Date for review 13.02.20
© College of Optometrists

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