Understanding Ocular Rosacea

By Miss Jennifer Doyle / 19 Nov 2019

Ophthalmologist Miss Jennifer Doyle explores the diagnosis and treatment of ocular rosacea

Rosacea is a treatable yet incurable common chronic inflammatory skin condition.1 Many aesthetic treatments including medical grade skincare,2 chemical peels3 and laser treatments4 can improve the skin redness and visible blood vessels that are associated with the concern. With this in mind, rosacea patients are often seen within aesthetic practice. Ocular involvement can occur in 58-72% of rosacea patients.5,6 

With rosacea being a common disease particularly amongst Caucasians; with a prevalence of up to 22% in some populations,7,8 this amounts to a significant number of people being affected. This article aims to help practitioners understand the nature of ocular rosacea, the eye conditions that it can cause, and what treatments are available.

What is ocular rosacea?

Rosacea can be split into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular (Table 1).9 Ocular rosacea is a subtype of rosacea that presents around the periorbital region and can lead to sight-threatening complications,10 which can usually be avoided with prompt recognition of the condition and referral to an ophthalmologist. Aesthetic practitioners may be the first point of contact for rosacea patients, so knowing the signs and symptoms of ocular involvement is important as they may be able to help patients seek specialist advice in a timely manner. 

Table 1: The four subtypes of rosacea9

The exact pathological mechanisms of rosacea remain poorly understood, although several studies indicate that an inflammatory response is involved.11-16 Ocular rosacea results in inflammation of the eyelids and the ocular surface itself.17,18 Studies analysing the tears of patients with ocular rosacea have found increased levels of pro-inflammatory cytokines such as interleukin 1α & β and metalloproteinase-8 and 9.11-14 

Patients with ocular rosacea may complain of symptoms including: eye irritation, foreign body sensation, stinging or burning sensation, sensitivity to light, watering of the eyes and blurriness of vision.18 Symptoms can range in severity and often patients with ocular rosacea will also present with other subtypes. However, no correlation has been found between the severity of the ocular disease and facial rosacea.19

Presentation of ocular rosacea

Ocular rosacea can affect the eyelids as well as the ocular surface, resulting in blepharitis, conjunctivitis or even corneal involvement in more severe cases.

Blepharitis

Blepharitis, or inflammation of the eyelid margin, can occur with ocular rosacea.20 You may notice that the eyelid margin and along the lash line looks red. The skin can become thickened and there may be telangiectatic blood vessels. Meibomitis is a type of blepharitis typically affected in rosacea and occurs when inflammation is located specifically to the meibomian glands on the posterior edge of the lid margin. This is different to anterior blepharitis which results in build-up of debris and bacteria along the base of the eyelashes. The meibomian glands (also known as tarsal glands) within the eyelid, secrete the oily part of our tear film.

When they become inflamed or blocked this can result in a swelling known as a chalazion or ‘stye’.21 These glands are often involved in ocular rosacea.20,21 As the meibum (the oily part of the tear film) is not properly secreted in patients with meibomitis, the tears evaporate more easily, leading to dry eye disease. Patients experience ocular irritation as a result, and it can lead to the surface of the eye becoming inflamed or damaged. It can also lead to redness of the surface of the eye.

The mainstay of managing meibomitis is different to anterior blepharitis and involves conservative treatment such as lid hygiene, which involves applying hot compresses to the lids followed by massaging the eyelids.19 The aim of this treatment is to use heat to liquify the stagnant secretions in the glands, before massaging the lids to express these secretions to the tear film. 

It has been found that this treatment improves the tear film stability and reduces the damage to the ocular surface.22,23

Conjunctivitis

Inflammation of the eyelids and poor tear film quality can lead to inflammation of the conjunctiva, the thin transparent layer that covers the inner surface of the eyelids and the sclera (white of the eye). When this layer of tissue becomes inflamed, this is called conjunctivitis.24,25

Practitioners may notice that the white of the eye looks red and sore. In patients with rosacea, this can become chronic, resulting in longstanding sore and red eyes.25 Inflammation of the conjunctiva is thought to be due to dryness of the ocular surface, along with the underlying inflammatory response that is believed to relate to the disease process of rosacea, as mentioned above.24

Dry eye drops, also known as lubricating eye drops, are often the first treatment approach and can help to protect the ocular surface.23 For flare-ups of conjunctivitis related to rosacea, topical steroid eye drops can be used temporarily to settle the inflammation.24 These should only be used under the supervision of an ophthalmologist and only for short-term therapy, as they can cause problems such as increased pressure within the eye and cataract.25

Studies analysing the tears of patients with ocular rosacea have found increased levels of pro-inflammatory cytokines such as interleukin 1α & ß and metalloproteinase-8 and 9
Figure 2: The anatomy of the eye32

Corneal involvement

In more severe cases, ocular rosacea can affect the cornea. The cornea (shown in Figure 2) is the clear window at the front of the eye, which is in front of the iris or coloured part of the eye. When the cornea becomes inflamed, this is called keratitis. 

As the cornea is the clear window that we see out of, if this area becomes affected, it can result in a reduction of vision. It is thought that up to one third of patients with rosacea have corneal involvement at some stage of their disease.5,26 This normally starts in the top layer of the cornea, the epithelium, resulting in a superficial punctate keratitis. Once this barrier is breached, it can lead to deeper layers of the cornea becoming involved and corneal ulcers and vascularisation can occur.19

In these cases, as well as topical and conservative treatments, oral therapeutics may be recommended. Oral tetracyclines such as doxycycline not only have an antibacterial effect, but also have an immunomodulatory effect.27,28,29 They have been shown to reduce the expression of MMPs,28 which as mentioned, are thought to play a proinflammatory role within rosacea. A typical regimen that may be used would be 100mg doxycycline taken once a day orally for a threemonth period.30 It must be noted that advice or referral to a specialist in this field should be sought before offering treatment.

Other considerations

It is important to remember that suffering with a chronic disease like rosacea can take its toll psychologically, affecting the patient’s quality of life and having socioeconomic impacts.31 As the disease primarily affects the skin of the face and the eyes, it is easily visible to others and difficult to hide. Whilst the skin complaints affect a person cosmetically, it is important to remember that the ocular effects can, in severe cases, result in sight loss.10 It has been reported that up to a third of patients with ocular rosacea have potentially sight threatening corneal findings.10

I recommend that if any rosacea patient describes any symptoms or exhibit any signs of ocular involvement, practitioners advise them to seek specialist input from an ophthalmologist. For mild and non-acute cases, a local optometrist (optician) may be a good first point of call. 

They can examine the eyelids and ocular surface, and in mild cases of blepharitis they can advise patients on conservative treatments such as lid hygiene, and can recommend and supply lubricating eye drops. Optometrists can also check for signs of more severe disease and arrange referral to an ophthalmologist if necessary. If practitioners are worried about a patient presenting with severe acute eye symptoms, knowing the referral pathways to the local eye casualty service for advice and assessment is important. 

Catching the ocular disease early and arranging for the patient to have education and guidance on how to manage it can mean avoiding the more severe complications later down the line.

Summary

Rosacea can affect the eyes as well as the skin, and can result in complications affecting vision. It affects the eyelids and ocular surface including the conjunctiva and cornea. Symptoms and signs you may notice are irritation of the eyes, and redness of the eyes or eyelids. If you do identify a patient with ocular involvement, referring them to an optometrist or ophthalmologist as appropriate can help prevent more serious ocular disease.

References
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