eMedicine Specialties > Ophthalmology > Dermatologic Disorders

Ocular Rosacea

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
Coauthor(s): Evan S Loft, MD, Staff Physician, Department of Ophthalmology, Emory University; C Diane Song, MD, Chief of Ophthalmology, Asheville Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Feb 20, 2009

Introduction

Background

Rosacea is a dermatologic condition that affects the midfacial region.^1,2,3,4  The nose, cheeks, forehead, chin, and glabella are most commonly affected.  Clinical features include flushing, telangiectasias, erythema, papules and pustules, and rhinophyma. More than 50% of patients with rosacea have ocular manifestations. 

Ocular rosacea is most frequently diagnosed when cutaneous signs and symptoms of the condition are also present. However, ocular signs and symptoms may occur prior to cutaneous manifestations in 20% of patients with rosacea. No correlation exists between the severity of ocular disease and the severity of facial rosacea.

Ocular manifestations are essentially confined to the eyelids and ocular surface.^5,6    Problems range from minor irritation, dryness, and blurry vision to potentially severe ocular surface disruption and inflammatory keratitis. Blepharitis and conjunctivitis are the most common findings in patients with ocular rosacea.  Other ocular findings include lid margin and conjunctival telangiectasias, eyelid crusts and scales, punctate epithelial erosions, corneal infiltrates, corneal ulcers, and vascularization.  Sight-threatening disease is rare with rosacea; however, keratitis can result in sterile corneal ulceration and eventual perforation if not treated aggressively.

The symptoms of rosacea can be treated effectively; however, rosacea is a chronic condition with exacerbations and remissions, which requires long-term therapy to maintain symptomatic control.

Pathophysiology

The precise pathophysiology of rosacea remains unknown.^7,8 Rosacea manifests itself primarily as a cutaneous vascular disorder; however, inflammatory changes are a hallmark of severe rosacea. Thus, rather than a specific disease entity, rosacea may be thought of as a disease spectrum with 2 primary etiologic components, vascular and inflammatory. The earliest manifestations of the disease are cutaneous vascular dilatory changes with subsequent increased blood flow in the form of telangiectasias and erythema. Sunlight-induced small vessel damage may contribute to this underlying vascular instability.

The later stages of rosacea are marked by inflammatory changes in the form of papules and pustules in the midface, rhinophyma (bullous nose), blepharitis and meibomitis, and corneal vascularization. A type 4, cell-mediated hypersensitivity reaction has been hypothesized as a possible mechanism. Demodex mites also have been implicated as a possible inflammatory stimulus. Additionally, Helicobacter pylori has been postulated to be a causative factor in a subset of patients. Whatever the underlying mechanism, there is a fundamental abnormality in the sebaceous glands of the face and eyelids, which leads to the inflammatory changes exhibited.

Frequency

United States

More than 10% of the general population exhibits dermatologic characteristics of rosacea; of these, up to 60% experience ocular complications.

Mortality/Morbidity

Rosacea is not a life-threatening disease. Approximately 5% of patients with rosacea manifest corneal disease, which may be severe and can lead to blindness via corneal ulceration, perforation, secondary infections, or corneal opacification from complete vascularization.

Race

Rosacea is recognized much more commonly in fair-skinned, white patients but also occurs in other populations and actually may be underreported, rather than less prevalent, in races with increased skin pigmentation.

Sex

Women are affected with rosacea twice as often as men; however, disease manifestations, especially rhinophyma, are frequently more severe in men than in women. The occurrence of ocular manifestations is approximately equal between men and women.

Age

All ages can be affected, including pediatric patients.⁹ Peak incidence occurs in the fourth to seventh decades.

Clinical

History

• Facial symptoms
  • Recurrent flushing episodes
  • Persistent and/or recurrent midfacial erythema
  • Acne (adult onset)
• Ocular symptoms
  • Dry eyes¹⁰ , irritation, redness, itching, burning, foreign body sensation, and photophobia
  • Recurrent styes
  • Recurrent eye infections

Physical

• Facial findings
  • Telangiectasias
  • Papules and pustules (without comedones)
  • Rhinophyma (hypertrophy of sebaceous glands of the nose leading to bullous tissue hyperplasia)
• Ocular findings
  • Eyelid (most common)¹¹
    • Eyelid telangiectasias
    • 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
    • Corneal thinning, ulceration, and perforation
  • Secondary bacterial keratitis
  • Episcleritis, scleritis (rare)

Causes

• Flushing triggers - Alcohol, hot beverages, tobacco, spicy foods, vasodilating medications, and emotional stress
• UV sunlight - 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.¹²
• Demodex - Postulated to increase the inflammatory reaction of the sebaceous glands.  Prevalence of infestation approximates 100% in healthy middle-aged or older adults.
• H pylori - Postulated to be correlated strongly with rosacea. This is possibly due to a flush-inducing toxin present in H pylori.

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