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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