Ocular rosacea

What is it ocular Rosacea?

Rosacea is a common skin problem in which there is redness of the middle of the face, redness, prominent vasculature, swelling, papules me pustules. Ocular rosacea is a form of rosacea that involves the eyelids and the front of the eye. Ocular rosacea includes:

• Blepharitis
• Conjunctival hyperemia
• Associated with rosacea keratitis

Who gets ocular rosacea?

Ocular rosacea affects adult men and women equally, with one study reporting a median age of presentation of 56 years. It is rare in children and usually begins after age 30.

It usually occurs in patients with existing rosacea, but may be the first sign of the disease Ocular rosacea tends to occur in patients with facial redness (1).

What is the cause of ocular rosacea?

The exact cause of ocular rosacea is unknown. However, immune micro-factorsorganisms on the surface of the skin, and reactive blood vessels are involved (1).

• Demodex Mites, normal inhabitants of eyelashes follicles, can stimulate inflammation in ocular rosacea and previous blepharitis
• The bacteria may play a role, as ocular rosacea improves with antibiotics. One theory is that bacterial lipase release toxic free fatty acids and glycerides lipids secreted by meibomina glands.
• Pro-inflammatory cytokine interleukin 1-alpha (IL-1α) increases metallomatrix protein-9 (MMP-9) in tear fluid. Upregulation of MMP-9 damages ocular tissues.

Blockage of the meibomian glands changes the composition of the tear film and leads to:

• Reduced tear film lipid cap
• Tear film instability
• Tear hyperosmolarity

What are the symptoms of ocular rosacea?

Ocular rosacea mainly affects the eyelids, conjunctiva and cornea. Rarely, it may involve the iris and sclerotic. Symptoms may include:

• itching
• Burning and pain
• Increased tears
• Photophobia (sensitivity to light)
• Foreign body sensation.
• Dry Eye
• inflamed papules
• Corneal ulcers
• Red eye

What are the clinical signs of ocular rosacea?

Eyelid and conjunctiva

Anterior blepharitis involves the eyelid margin and eyelash line. Signs include:

• Swelling and thickening of the eyelid margin.
• Redness and dilated blood vessels.
• Scaly remains at the base of the eyelashes
• Loss of eyelashes (madarosis) or misdirected eyelashes.

Later Blepharitis involves obstruction of the ducts and loss of the meibomian glands (2). This leads to:

• Conjunctival hyperemia (dilated conjunctival vessels)
• Cloudy secretions
• Papillary and follicular tarsal plate reactions
• Conjunctival scarring
• Chalaziones (granulomatous inflammatory lesions around the meibomian glands)
• Hordeolum externum (sty, i.e. eyelashes infection with Staphyloccocus aureus)

Cornea

An inflamed cornea (keratitis) is a rare but serious ocular complication of rosacea and can threaten vision (1).

• Keratitis can affect one or both eyes.
• The thinned cornea becomes inflamed with superficial stippling. erosions, increased blood vessels and opacities.
• Keratitis due to ocular rosacea tends to start at one edge or bottom of the eye and then spread to affect the lower half of the two-thirds of the cornea.
• Recurrent Attacks lead to corneal thinning, increased corneal opacity, and vessel invasion.
• Severe eye disease can rarely result in descemetocele (deep ulcer) and corneal drilling.
• Corneal disease may include the formation of pannus (a layer of vascular fibrous tissue) and phlyctenules (allergic cornea nodules)

Iris and sclera

• Iritis: inflamed iris
• Episcleritis: inflammation of the layer between the conjunctiva and the cornea.
• Scleritis: inflammation of the white of the eye

Iritis, episcleritis, and scleritis are rare in ocular rosacea. They cause painful, watery red eyes and can affect vision.

How is ocular rosacea diagnosed?

Ocular rosacea may be suspected in a patient with cutaneous rosacea that has eyelid or eye disease. Symptoms and signs are nonspecific, so diagnosis is more difficult in the absence of cutaneous rosacea.

Blepharitis can also be caused by seborrheic dermatitis, a scaly skin condition and inflammatory papules on and around the eyelids may be due to periorificial dermatitis.

What are the treatment options for ocular rosacea?

Conservative treatment

• Lid hygiene: diluted baby shampoo, diluted baking soda solution or the proprietary preparation can be applied with a cotton swab to clean the eyelid margins and remove scale along the lash line.
• Warm compresses on closed eyelids for five to ten minutes daily can improve the flow of secretions from the meibomian gland, chalazion, and stye.
• Artificial tears (eye lubricants) reduce symptoms due to dry eye.
• Avoid wearing contact lenses if they irritate the inflamed eye.

Current antimicrobials

Anterior blepharitis can be successfully treated with various topical antiseptics and antibiotics including:

• Erythromycin
• Metronidazole
• Azithromycin
• Bacitracin
• Polymyxin B
• Fusidic acid

Current anti-inflammatory agents

• Topical nonsteroidal anti-inflammatory agents such as ibuprofen may be helpful.

• Topical steroids are used short-term to treat marked inflammation of the eyelid or rosacea keratitis. Long-term use of topical steroids should be avoided as they can lead to glaucoma and waterfalls.

• Topical cyclosporine is typically used in ocular rosacea that has not responded to topical steroids.

Systemic antibiotics

The following oral antibiotics are used for ocular rosacea:

• Tetracyclines such as doxycycline.

• Macrolides such as erythromycin

They reduce bacteria, improve the stability of the tear film and normalize the secretions of the meibonic glands.

Oral antibiotics are usually continued for 6 to 12 weeks, and then slowly tapered over the course of one to two months. Additional courses of oral antibiotics may be used for disease flares.

Styes that do not clear up with topical antibiotics are treated with oral antistaphylococcal antibiotics such as flucloxacillin.

Oral retinoids

Oral isoretinoin can be used in low doses to treat ocular rosacea, but with caution because its adverse effects include increased infections, dry eyes, and other ocular effects.

Omega-3 fatty acid supplements

Oral supplementation with omega-3 fatty acids has been reported to be beneficial for some patients with dry eyes.

Surgical intervention

Surgery may be required to repair corneal opacification or perforation due to rosacea keratitis. The procedure is called keratoplasty.

Hordeola that does not improve with warm compresses and antibiotic therapy can be removed.