Aetiology

Ocular manifestation of rosacea, a chronic relapsing inflammatory condition of the skin predominantly affecting the centrofacial region (cheeks, nose, and forehead). Multifactorial pathophysiology, including genetic susceptibility, environmental factors (e.g. UV radiation, spicy foods, alcohol), Multifactorial pathophysiology, including genetic susceptibility, environmental factors (e.g. UV radiation, spicy foods, alcohol), and presence of immunogenic stimuli due to microorganisms on the skin, particularly parasites such as Demodex species and bacteria such as Bacillus oleronius and Staphylococcus epidermidis.

Predisposing factors

Rosacea is a common skin disorder (global prevalence in the general adult population approx. 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 the majority 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 manifestations and the severity of the cutaneous disease

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

Signs of ocular rosacea

Lids and tear film

• hyperaemic thickened lids
• telangiectasia of the lid margins
• posterior marginal blepharitis
• may have associated signs of anterior blepharitis
• recurrent acute lid infections (chalazion, hordeolum (stye))
• tear film instability (short tear breakup time (TBUT)) and/or deficiency

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
• marginal keratitis
• corneal thinning (may lead to perforation)
• scarring secondary to corneal involvement
• sclerokeratitis

Conjunctiva

• bulbar and/or palpebral hyperaemia

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/infectious keratitis
Other causes of chronic blepharitis

Management by optometrist

Practitioners should work within their scope of practice, 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 management of associated blepharitis (see Clinical Management Guideline on Blepharitis)

Advice on avoiding the causes of exacerbations (including facial flushing) if these have been identified by the patient

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

Consider Omega 3 fatty acid supplementation

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

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

(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)

• 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)

Topical antibiotic therapy: e.g. azithromycin (off-label use)

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

Oral tetracyclines antibiotic therapy: e.g., 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 ideally should follow confirmed diagnosis of (cutaneous) rosacea

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

Short term mild topical steroids if exacerbation with no corneal ulceration

NB All patients on topical steroid drops or ointment should have their intraocular pressures checked initially, then measured again at appropriate intervals e.g. 2 weeks and every 4 weeks for 2-3 months (see Clinical Management Guideline on Steroid Glaucoma)

(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 in secondary care or local primary/community pathways where available

Additional guidance may be available

Co-management between dermatology and ophthalmology
Topical ciclosporin (unlicensed indication)
Topical steroid for management of severe corneal disease
Topical Ivermectin cream to eyelid skin
Surgical interventions to manage severe corneal complications

Evidence base

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

Sources of evidence

Avraham S, Khaslavsky S, Kashetsky N, Starkey SY, Zaslavsky K, Lam JM, Mukovozov I. Treatment of ocular rosacea: a systematic review. J Dtsch Dermatol Ges. 2024 Feb;22(2):167-174. doi: 10.1111/ddg.15290. Epub 2024 Jan 20.

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

Malagón-Liceaga A, Recillas-Gispert C, Ruiz-Quintero NC, Ruelas-Villavicencio AL. Treatment of ocular rosacea: A practical review from an interdisciplinary approach. Arch Soc Esp Oftalmol (Engl Ed). 2023;98(10):577-585.

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 12
Date of search 16.03.24
Date of revision 02.05.24
Date of publication 10.06.24
Date for review 15.03.26
© College of Optometrists