Ocular Rosacea Clinical Presentation

  • Author: J Bradley Randleman, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Aug 23, 2011
 

History

  • Facial symptoms
    • Recurrent flushing episodes
    • Persistent and/or recurrent midfacial erythema
    • Acne (adult onset)
  • Ocular symptoms
    • Dry eyes,[13] irritation, redness, itching, burning, foreign body sensation, and photophobia
    • Recurrent styes
    • Recurrent eye infections
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Physical

Facial findings

  • Telangiectasias
  • Papules and pustules (without comedones)
  • Rhinophyma (hypertrophy of sebaceous glands of the nose leading to bullous tissue hyperplasia)
  • See the image belowTypical findings of rosacea, including papules, puTypical findings of rosacea, including papules, pustules, and rhinophyma.

Ocular findings

  • Eyelid (most common)[14]
    • Eyelid telangiectasias as depicted belowOcular rosacea. Eyelid telangiectasias with inspisOcular rosacea. Eyelid telangiectasias with inspissated meibomian glands.
    • Blepharitis
    • Meibomian gland dysfunction
    • Thick viscous plugging of meibomian gland orifices
    • Hordeola/chalazia
  • Conjunctivitis
    • Usually chronic, diffuse hyperemia
    • Can lead to cicatrization in rare, severe cases
  • Corneal findings
    • Punctate epithelial keratopathy (PEK), usually in the inferior one third of the cornea
    • Marginal corneal infiltrates
    • Corneal neovascularization
    • Superficial, wedge-shaped peripheral vascularization with its base at the limbus
    • Can progress to frank corneal neovascularization and eventual opacification as shown belowOcular rosacea. Extensive corneal neovascularizatiOcular rosacea. Extensive corneal neovascularization and opacification.
    • Corneal thinning as depicted below, ulceration, and perforationOcular rosacea. Extensive corneal pannus with thinOcular rosacea. Extensive corneal pannus with thinning.
  • Secondary bacterial keratitis
  • Episcleritis, scleritis (rare)
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Causes

  • Flushing triggers: These include alcohol, hot beverages, tobacco, spicy foods, vasodilating medications, and emotional stress.
  • UV sunlight: This is postulated to decrease the competence of already dilated cutaneous vasculature, increasing persistent erythema and telangiectasias.
  • Migraines: Studies have shown an increase in rosacea in patients with migraine headaches. It is postulated that patients with rosacea have a vasculature prone to vasodilation.[15]
  • Demodex: This is Postulated to increase the inflammatory reaction of the sebaceous glands. Prevalence of infestation approximates 100% in healthy middle-aged or older adults.
  • H pylori: This is postulated to be strongly correlated with rosacea. This is possibly due to a flush-inducing toxin present in H pylori.
  • Positive family history: Some studies have shown a higher rate of positive family history of rosacea in patients with this dermatologic disorder than in skin-healthy controls.[16]
  • Smoking: Some studies have shown an increased history of smoking in patients with rosacea as compared with skin-healthy controls.[16, 17]
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Contributor Information and Disclosures
Author

J Bradley Randleman, MD  Associate Professor, Department of Ophthalmology, Section of Cornea, External Disease and Refractive Surgery, Emory University School of Medicine; Director of Cornea, External Disease and Refractive Surgery Fellowship, Emory University; Physician Member, Section of Ophthalmology, The Emory Clinic

J Bradley Randleman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Cornea Society, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Evan S Loft  MD, Clinical Assistant Professor, Department of Ophthalmology, Emory University

Evan S Loft is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

C Diane Song, MD  Chief of Ophthalmology, Asheville Veterans Affairs Medical Center

C Diane Song, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Bhairavi Kharod-Dholakia, MD  Director, Refractive Service, Assistant Professor, Department of Ophthalmology, University of Arkansas for Medical SciencesAssistant Professor, Department of Ophthalmology, Emory University

Disclosure: Nothing to disclose.

Sheetal M Shah, MD  Associate Professor, Department of Ophthalmology Emory Eye Center and Emory Vision

Sheetal M Shah, MD is a member of the following medical societies: American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Fernando H Murillo-Lopez, MD  Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.

References

  1. Buechner SA. Rosacea: an update. Dermatology. 2005;210(2):100-8. [Medline].

  2. Knox CM, Smolin G. Rosacea. Int Ophthalmol Clin. Spring 1997;37(2):29-40. [Medline].

  3. Powell FC. Clinical practice. Rosacea. N Engl J Med. Feb 24 2005;352(8):793-803. [Medline].

  4. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. Apr 2002;46(4):584-7. [Medline].

  5. Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. Nov 1997;104(11):1863-7. [Medline].

  6. Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol. Nov-Dec 1986;31(3):145-58. [Medline].

  7. Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol. Mar 1994;130(3):359-62. [Medline].

  8. Tisma VS, Basta-Juzbasic A, Jaganjac M, et al. Oxidative stress and ferritin expression in the skin of patients with rosacea. J Am Acad Dermatol. Feb 2009;60(2):270-6. [Medline].

  9. Sobottka A, Lehmann P. Rosacea 2009 : new advances in pathophysiology, clinical staging and therapeutic strategies. Hautarzt. Dec 2009;60(12):999-1009. [Medline].

  10. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol. 1989;69(5):419-23. [Medline].

  11. Abram K, Silm H, Oona M. Prevalence of rosacea in an Estonian working population using a standard classification. Acta Derm Venereol. May 2010;90(3):269-73. [Medline].

  12. Chamaillard M, Mortemousque B, Boralevi F, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol. Feb 2008;144(2):167-71. [Medline].

  13. Viso E, Rodriguez-Ares MT, Gude F. Prevalence of and associated factors for dry eye in a Spanish adult population (the Salnes Eye Study). Ophthalmic Epidemiol. Jan-Feb 2009;16(1):15-21. [Medline].

  14. Icasiano E, Latkany R, Speaker M. Chronic epiphora secondary to ocular rosacea. Ophthal Plast Reconstr Surg. May-Jun 2008;24(3):249. [Medline].

  15. Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani P. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol. Jul 15 1993;116(1):88-92. [Medline].

  16. Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol. May 2010;24(5):565-71. [Medline].

  17. Breton AL, Truchetet F, Veran Y, et al. Prevalence analysis of smoking in rosacea. J Eur Acad Dermatol Venereol. Sep 2011;25(9):1112-3. [Medline].

  18. Modi S, Harting M, Rosen T. Azithromycin as an alternative rosacea therapy when tetracyclines prove problematic. J Drugs Dermatol. Sep 2008;7(9):898-9. [Medline].

  19. Alikhan A, Kurek L, Feldman SR. The role of tetracyclines in rosacea. Am J Clin Dermatol. 2010;11(2):79-87. [Medline].

  20. Barnhorst DA Jr, Foster JA, Chern KC, Meisler DM. The efficacy of topical metronidazole in the treatment of ocular rosacea. Ophthalmology. Nov 1996;103(11):1880-3. [Medline].

  21. Luchs J. Azithromycin in DuraSite for the treatment of blepharitis. Clin Ophthalmol. Jul 30 2010;4:681-8. [Medline]. [Full Text].

  22. Torresani C. Clarithromycin: a new perspective in rosacea treatment. Int J Dermatol. May 1998;37(5):347-9. [Medline].

 
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Typical dermatologic findings of rosacea, including midfacial papules, pustules, and rhinophyma.
Typical findings of rosacea, including papules, pustules, and rhinophyma.
Ocular rosacea. Eyelid telangiectasias with inspissated meibomian glands.
Ocular rosacea. Peripheral corneal pannus.
Ocular rosacea. Extensive corneal pannus with thinning.
Ocular rosacea. Extensive corneal neovascularization and opacification.
 
 
 
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