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CLINICAL MANAGEMENT GUIDELINES
Ocular rosacea
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 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
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
Ocular rosacea
Version 8, Page 1 of 3
Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Ocular rosacea
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)
•
Pharmacological
•
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, Blepharitis, Dry Eye)
Ocular lubricants for tear deficiency/instability related symptoms
(drops for use during the day, unmedicated ointment for use at
bedtime)
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: A systemic drug of the tetracycline family,
specifically tetracycline, oxytetracycline, or doxycycline
(unlicensed indication) (all contraindicated in pregnancy, lactation
& 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)
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 and/or systemic azithromycin (unlicensed indication)
Topical steroid for management of corneal disease
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
Management Category
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
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
Stone DU, Chodosh J. Oral tetracyclines for ocular rosacea: an
evidence-based review of the literature. Cornea. 2004;23(1):106-9
Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed.
Ocular rosacea
Version 8, Page 2 of 3
Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Ocular rosacea
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 8, Page 3 of 3
Date of search 12.11.15; Date of revision 24.02.16; Date of publication 29.03.16; Date for review 11.11.17
© College of Optometrists