Ocular Rosacea 

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

See the image below.

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 thickening, eyelid crusts and scales, chalazia and hordeolum, punctate epithelial erosions, corneal infiltrates, corneal ulcers, corneal scars, 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.

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. Rosacea may be thought of as a disease spectrum with 2 primary etiologic components, vascular and inflammatory. Studies suggest an altered innate immune response as an underlying mechanism for the vascular and immune manifestations of rosacea.^[9] 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.

International

An epidemiological study in Sweden showed a 10% prevalence of rosacea.^[10] A study in Estonia showed a 22% prevalence rate of rosacea, as determined by the American National Rosacea Society Expert Committee (NRSEC) classification.^[11]

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.^[12] Peak incidence occurs in the fourth to seventh decades.