Introduction

Rosacea is an inflammatory skin condition that most commonly affects the central face.¹ Symptoms include episodes of facial flushing, permanent redness, burning and stinging sensation, telangiectasia (small but visible blood vessels) over the forehead, cheeks, chin and nose.^1,2,3 Rosacea is a chronic condition that waxes and wanes throughout its course and can cause significant distress to those affected.^1,4

Prevalence of rosacea in the general population is about 5%.¹

Rosacea that affects the eyes and eyelids is called ocular rosacea. Ocular Rosacea usually starts after the age of thirty and is equally common in males as it is in females.⁴ It usually affects those with existing rosacea but can be the presenting feature.⁴ More than 50% of those with rosacea have ocular rosacea.³

Background definitions

In order to jump straight into this topic some background definitions will be helpful along with knowledge of anatomy. 

• Blepharitis is inflammation of the eyelid margin¹ 
• Conjunctivitis is the inflammation of the layer over the inner surface of the eyelids, the conjunctiva
• Keratitis is the inflammation over the cornea¹
• Meibomian glands run along the inner surface of the eyelids producing a lipid secretion forming an important part of the tear⁵

Symptoms of ocular rosacea

Symptoms of ocular rosacea in the eyes and eyelids include:^2,3,4

• Gritty feeling of the eyes
• Feeling of something in the eye
• Irritation
• Blurring of vision
• Red eye
• Light sensitivity
• Tearing/watering of the eyes

Finding on examination in ocular rosacea include:^3,4

• Telangiectasia of lid margins and of the conjunctiva 
• Thickening of the eyelids
• Crusting and scaling of the eyelid margin
• Loss of eyelashes or misdirection of eyelashes 
• Chalazions (inflammatory lumps around glands that sit in the eyelids)
• Stye

If the cornea is affected keratitis can occur with thinning of the cornea. Ongoing inflammation can cause ulcers, erosions and scarring.⁴

The exact cause of rosacea is not known.^3,4 It is thought microorganisms on the skin surface and altered immune responses are involved. Demodex mites which are found in the eyelash follicles may cause inflammation resulting in blepharitis.^3,4 Bacteria may also play a role, as symptoms often improve with antibiotics and are part of treatment.^3,4 

Destruction of the meibomian glands, which are on the eyelids and are important for lubricating the eye, causes damaging changes to the tears.⁴

Generally, Rosacea can be triggered by: 

• Stress
• Sunlight
• hot/cold weather
• Hot drinks
• Foods including spicy foods/caffeine

Other skin conditions that cause similar symptoms are differential diagnoses and include seborrhoeic dermatitis and periorificial dermatitis.⁴

Diagnosis is clinically made with examination for signs and symptoms present and is more easily made in those who have rosacea elsewhere on the skin.⁴

Treatment options

Avoidance of triggers, for example, hot drinks, spicy foods, and alcohol can reduce flares in addition to avoidance of sunlight and use of sun protection.³ 

Conservative treatment

• Lid hygiene is important. Using a baby shampoo and cotton wool bud, lid margins can be cleaned to remove debris buildup^3,4 
• Warm/hot compresses to the eyelids to help meibomian gland secretion flow and ease expression of secretions.^3,4 Gentle pressure may also aid gland secretion³

Artificial tears to help dry eyes multiple times a day in addition to an ointment at night time.^3,4

Topical antimicrobials

Topical antibiotics are an option for blepharitis symptoms.

Topical anti-inflammatory agents

Topical non-steroid medications such as ibuprofen can provide results. 

Topical steroids are an option to treat significant lid disease or keratitis but should be used for a short period of time under a specialist's supervision as long-term use can lead to glaucoma and cataracts.^3,4

Topical ciclosporin can be used on those not responding to topical steroids or when disease regression is dependent on steroids and thus to limit steroid use.⁴ 

Oral antibiotics

For example doxycycline and erythromycin. These both act as antibiotics but also at the meibomian gland level improving gland secretions.^3,4 Oral antibiotics treatments are continued for 6-12 weeks and can be repeated for flare-ups. 

Retinoids

Topical and oral treatment exist. However, they are used in cases where other treatments have failed and with caution as they can actually cause adverse ophthalmological effects such as infections and keratitis. They are also extremely teratogenic (that is they can cause malformations of a developing baby) and so must never be used in pregnancy or those at risk of pregnancy.³

Surgical treatment

Keratoplasty can repair corneal disease and perforation.^3,4 Surgical excision of stye that fails to respond to compression and antibiotics treatment is also an option.^3,4

Summary

Treatment options are directed at symptomatic control rather than cure. Complications of ocular rosacea can be serious including scarring of the eyes and can affect vision thus it is important that the symptoms and signs are recognised by patients and healthcare professionals and managed appropriately.