eMedicine Specialties > Ophthalmology > Dermatologic Disorders
Ocular Rosacea
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)
- Eyelid (most common)11
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.
Differential Diagnoses
| Blepharitis, Adult | Corneal Erosion, Recurrent |
| Central Sterile Corneal Ulceration | Dermatitis, Atopic |
| Chalazion | Dry Eye Syndrome |
| Chlamydia | Episcleritis |
| Cicatricial Pemphigoid | Keratitis, Bacterial |
| Conjunctivitis, Allergic | Keratoconjunctivitis, Atopic |
| Conjunctivitis, Bacterial | Keratoconjunctivitis, Sicca |
| Conjunctivitis, Viral | Ulcer, Corneal |
Workup
Laboratory Studies
- The diagnosis of ocular rosacea is established clinically and is often aided by dermatologic findings. Laboratory studies are not indicated.
Imaging Studies
- Imaging studies are not indicated.
Other Tests
- Other tests are not indicated.
Histologic Findings
The conjunctiva in ocular rosacea is infiltrated by inflammatory cells, T-helper/T-suppressor (CD4) cells, phagocytic cells, and antigen-presenting cells. In addition, increased vascular dilation and occasionally granulomatous changes are present. None of these changes are specific for rosacea.
Patients with rosacea typically have a mean increase of nearly all cell types, but especially T-helper cells.
Hoang-Xuan et al demonstrated a 3.5-fold increase in the ratio of CD4 cells to CD8 cells in the conjunctiva of patients with rosacea, most resembling a type IV hypersensitivity reaction.13
Treatment
Medical Care
Rosacea is an enigmatic disease with multiple exacerbations and remissions, and, unfortunately, treatment is directed toward symptomatic control rather than cure. Ocular rosacea can manifest as minor ocular irritation or severe corneal compromise; thus, medical therapy is chosen based on the severity of presentation. When possible, a stepwise approach can be undertaken, using first lid hygiene and artificial tears, followed by topical and oral anti-inflammatory medications, with late surgical intervention as required.
As can be implied by the number and variety of treatment options available for rosacea, no one therapeutic regimen has been found effective in all cases, and many cases of rosacea are recalcitrant to multiple therapies. Therefore, treatment always must be tailored to each individual, and various options must be explored until symptoms begin to respond favorably.
- Lid hygiene: Hot compresses applied to the eyelid margins can help to liquefy the thick meibomian gland secretions and, thus, facilitate their expression. Mild, nonirritating cleaning solutions, such as dilute baby shampoo or commercially prepared eyelid scrubs, also can be applied to the eyelids to remove clogging debris. Additionally, light pressure applied to the eyelids can aid in gland expression.
- Artificial tears: Because of the frequency of application, nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.
- Antibiotics (Patients with ocular rosacea who are asymptomatic and without worsening eye disease should not be placed on oral antibiotics.)
- Tetracyclines (eg, tetracycline, doxycycline, minocycline)12,13
- Tetracyclines represent the most common and most effective treatment regimen for rosacea. These drugs are believed to be effective not primarily as antibiotics but rather through a secondary effect that they exert on the meibomian glands. Tetracyclines decrease bacterial lipase, thereby altering the fatty acid composition of the meibomian gland secretions and improving their solubility. These medications also inhibit collagenase; therefore, they are effective in protecting the cornea from impending perforation secondary to inflammatory responses.
- Adverse effects are predominantly gastrointestinal, including diarrhea and rarely pancreatitis and pseudomembranous colitis. More severe but much less common adverse effects include benign intracranial hypertension and renal tubular damage (Fanconi syndrome) from outdated medications. Additionally, tetracyclines cross the placenta and can cause permanent discoloration of teeth as well as retardation of fetal bone growth.
- Tetracyclines generally are effective for rosacea in doses much lower than those given for antibiotic effect, and, once the disease has come under control, the dose may be tapered to a lower, suppressive dose and maintained indefinitely. Because of the chronic, relapsing nature of rosacea, the medication may be used chronically at suppressive doses or discontinued and restarted if and when symptoms recur.
- Among this class of medications, tetracycline and doxycycline are most commonly used. The 2 medications are quite similar in their mechanism of action, adverse effect profile, and efficacy, but slight differences do exist. Tetracycline has a shorter half-life and, thus, is dosed 4 times per day, as opposed to doxycycline, which is given twice per day or once per day. Frucht-Pery et al reported a more rapid therapeutic response to tetracycline; however, no difference was found at 6 months.12 Additionally, the adverse effect profile is slightly more favorable for doxycycline.
- Erythromycin can be taken orally for patients intolerant to, or too young for, tetracyclines. Erythromycin ointment applied to the lid margins once or twice daily can provide lubrication for the eye and reduce the bacterial overgrowth contributing to lid margin disease.
- Clarithromycin has shown efficacy in treating rosacea. This compound exhibits anti-inflammatory effects as well as activity against H pylori. Torresani compared clarithromycin and doxycycline and found equivalent therapeutic responses and a milder adverse effect profile for clarithromycin.14
- Metronidazole
- Metronidazole exhibits antimicrobial (antibacterial and antiparasitic), anti-inflammatory, and immunosuppressive properties and has been found to be effective against rosacea. In fact, oral metronidazole has been advocated as first-line therapy. Adverse effects include gastrointestinal irritation and a disulfiramlike action; thus, abstinence from alcohol is required.
- Topical metronidazole is quite effective in treating skin lesions in rosacea. While not approved for ophthalmic use, in a pilot study, Barnhorst et al found the topical compound to be safe and effective in treating eyelid involvement in ocular rosacea.15
- Tetracyclines (eg, tetracycline, doxycycline, minocycline)12,13
- Topical steroids can prove useful for short-term exacerbations of lid disease and management of inflammatory keratitis. However, steroids should be used cautiously and discontinued as soon as possible to prevent corneal melting.
- Retinoids: Vitamin A derivatives, such as oral isotretinoin and topical tretinoin, have been found effective in reducing the inflammatory lesions in rosacea. This appears to be accomplished via the suppression of sebum production and a subsequent reduction in sebaceous follicle size. Additionally, tretinoin may help restore sun-damaged skin through the increased production of type 1 collagen in damaged regions. Both compounds actually can cause severe erythema and blepharoconjunctivitis, worsen telangiectasias, and lead to severe keratitis. Additionally, retinoids are extremely teratogenic and, thus, must never be used during pregnancy. Therefore, the use of retinoids is commonly reserved for cases in which multiple agents have failed.
- Antiulcer therapy: H pylori plays an as yet undetermined role in rosacea, and some have advocated H pylori eradication in the treatment of rosacea. Thus, in some cases of rosacea, antiulcer combination regimens, such as amoxicillin or clarithromycin, metronidazole, bismuth, and an H2 antagonist, have been used with varying efficacy.
Surgical Care
- Treatment of dry eye - Punctal occlusion can be accomplished via permanent silicone plugs or punctal cauterization.
- Amniotic membrane - Amniotic membrane has anti-inflammatory properties and promotes reepithelization of the cornea. It can be used to reconstruct the corneal surface in severe cases of rosacea when a nonhealing epithelial defect, corneal ulceration, or limbal stem cell deficiency are present.
- Treatment of corneal perforations
- Cyanoacrylate tissue adhesive
- Lamellar keratoplasty
- Penetrating keratoplasty
- Restoration of vision from corneal disease
- Penetrating keratoplasty
- The success rate for graft survival is generally much lower than for noninflammatory conditions because of the increased vascularization of the host cornea.
- Treatment of limbal stem cell deficiency - Limbal stem cell transplant
Consultations
A dermatology consult is essential for the optimal management of rosacea.
Diet
Avoidance of triggers, such as hot, spicy foods, alcohol, and heated beverages, can reduce symptomatic episodes.
Activity
Avoidance of sunlight can be beneficial for some patients.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antibiotics
Anti-inflammatory effect helps to ameliorate meibomian gland disease.
Tetracycline (Sumycin)
Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor.
Dosing
Adult
250 mg PO qid
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO divided q6h
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Contraindications
Documented hypersensitivity; use with caution in patients with renal impairment
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Vibramycin, Doryx)
DOC; inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor.
Dosing
Adult
100 mg PO qd/bid; can taper to 50 mg PO qd or qod
Pediatric
2.2 mg/kg PO qd/bid
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; concurrent use of vitamin A has been associated with increased intracranial pressure; antacids decrease the absorption of tetracyclines
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; caution in patients with hepatic insufficiency
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Effective through secondary, anti-inflammatory action.
Dosing
Adult
250-500 mg PO bid
Pediatric
7.5 mg/kg PO bid
Interactions
Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Contraindications
Documented hypersensitivity; coadministration of pimozide
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Metronidazole (Flagyl)
Has anti-inflammatory and immunosuppressive activity.
Dosing
Adult
250-500 mg PO bid/qid
Pediatric
7.5 mg/kg PO bid/qid
Interactions
Concurrent use with warfarin results in increased warfarin activity; concurrent use with cimetidine results in increased metronidazole levels; concurrent use with disulfiram results in combined toxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Extended use has been associated with the development of peripheral neuropathy, seizures, pancreatitis, leukopenia, and Clostridium difficile colitis
Erythromycin ophthalmic ointment (E-Mycin)
Used to decrease meibomian gland bacterial overgrowth.
Dosing
Adult
Apply to eyelid margins qhs/bid
Pediatric
Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Prolonged use may result in overgrowth of
nonsusceptible organisms, including fungi; discontinue use at first appearance of a skin rash or any other sign of hypersensitivity reaction
Retinoids
Decrease sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
Isotretinoin (Accutane)
Reduces sebum production and sebaceous follicle size.
Dosing
Adult
0.5-1 mg/kg/d PO divided bid
Pediatric
<12 years: Not recommended
>12 years: Administer as in adults
Interactions
Concurrent use with tetracyclines results in an increased risk for the development of pseudotumor cerebri; contraindicated with concurrent use of other topical acne medications
Contraindications
Documented hypersensitivity; females of childbearing age (has been shown to cause major fetal abnormalities)
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Do not donate blood while taking medication or within 30 d of discontinuing its use to prevent possible exposure for pregnant women; has been shown to cause corneal opacities and potentially severe blepharoconjunctivitis; has been shown to cause nosebleeds; can result in significant GI disturbances leading to discontinuation of use; exhibits cross-sensitivity with other vitamin A derivatives
Tretinoin (Avita, Retin-A, Retin-A Micro)
Structurally related to vitamin A. Reduces sebum production and sebaceous follicle size. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. May help restore sun-damaged skin. Long-term, low-dose therapy may be suitable for selected patients.
Inhibits microcomedo formation and eliminates lesions present. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
Dosing
Adult
Apply to eyelid margins qd/bid
Pediatric
<12 years: Not recommended
>12 years: Apply as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; use with other retinoids; use with other topical acne medications or astringents
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue if severe burning, stinging, or erythema develops; avoid unnecessary sun exposure; use of medication may worsen telangiectasias; exhibits cross-sensitivity to other vitamin A derivatives
Steroids
Topical steroids occasionally are needed to help suppress inflammatory changes in the cornea.
Prednisolone acetate (Pred Forte, Econopred)
Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.
Dosing
Adult
1 gtt OU q1-12h based on severity of inflammation
Pediatric
Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, fungal, or tubercular infections
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can increase corneal thinning and melting and lead to globe perforation; monitor IOP carefully, and discontinue topical steroids if an acute rise in pressure noted; discontinue steroids at first sign of active ocular surface infection
Immunomodulators
These agents regulate key regulatory steps responsible for inflammation.
Cyclosporine (Restasis)
Used to relieve dry eyes caused by suppressed tear production secondary to ocular inflammation. Thought to act as partial immunomodulator. Exact mechanism of action is not known.
Dosing
Adult
Instill 1 gtt in each eye q12h
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Interactions
None reported
Contraindications
Documented hypersensitivity; ocular infection
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Herpes keratitis; do not administer while wearing contact lenses; may cause ocular burning, conjunctival hyperemia, ocular discharge, excessive tearing, eye pain, foreign body sensation, pruritus, stinging, or blurred vision
Follow-up
Further Inpatient Care
- Inpatient care is rarely necessary, except in some cases of corneal perforations or severe secondary corneal infections.
Further Outpatient Care
- Rosacea is a chronic condition, and long-term management is necessary to control this disease.
- Dermatology and ophthalmology visits may be necessary, and they could initially be frequent to gain control over the symptoms or to protect an endangered cornea.
Inpatient & Outpatient Medications
- Lid hygiene
- Artificial tears
- Oral antibiotics - Doxycycline, tetracycline, clarithromycin, or metronidazole
- Erythromycin ointment
- Topical metronidazole
- Topical steroids
Deterrence/Prevention
- Patients should avoid trigger foods and situations.
- For some patients, avoidance of sunlight can minimize flare-ups.
Complications
- Complications include corneal vascularization, ulceration, perforations, secondary bacterial infections, and, ultimately, decreased vision.
- Eyes undergoing penetrating keratoplasty are more likely to experience graft rejection than eyes without rosacea because of the increased inflammatory response and the relatively increased corneal vasculature.
Prognosis
- Rosacea can be controlled symptomatically but is generally a chronic condition, which requires long-term, follow-up care.
Patient Education
- Informing patients of the chronic, relapsing nature of rosacea is important so that patient expectation matches available therapy and patient follow-up care is maximized.
- Ophthalmologists may underdiagnose rosacea because of a lack of familiarity with the dermatologic manifestations of the disease.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize, diagnose, and treat rosacea can compromise the integrity of the ocular surface.
Special Concerns
- Because rosacea is a chronic, often progressive disease, patients are likely to become increasingly symptomatic as they age.
- Patients need to understand that rosacea is a chronic condition, requiring long-term treatment.
Multimedia
Media file 1: Typical dermatologic findings of rosacea, including midfacial papules, pustules, and rhinophyma.
Media file 2: Typical findings of rosacea, including papules, pustules, and rhinophyma.
Media file 3: Ocular rosacea. Eyelid telangiectasias with inspissated meibomian glands.
Media file 4: Ocular rosacea. Peripheral corneal pannus.
Media file 5: Ocular rosacea. Extensive corneal pannus with thinning.
Media file 6: Ocular rosacea. Extensive corneal neovascularization and opacification.
References
Buechner SA. Rosacea: an update. Dermatology. 2005;210(2):100-8. [Medline].
Knox CM, Smolin G. Rosacea. Int Ophthalmol Clin. Spring 1997;37(2):29-40. [Medline].
Powell FC. Clinical practice. Rosacea. N Engl J Med. Feb 24 2005;352(8):793-803. [Medline].
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].
Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. Nov 1997;104(11):1863-7. [Medline].
Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol. Nov-Dec 1986;31(3):145-58. [Medline].
Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol. Mar 1994;130(3):359-62. [Medline].
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].
Chamaillard M, Mortemousque B, Boralevi F, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol. Feb 2008;144(2):167-71. [Medline].
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].
Icasiano E, Latkany R, Speaker M. Chronic epiphora secondary to ocular rosacea. Ophthal Plast Reconstr Surg. May-Jun 2008;24(3):249. [Medline].
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].
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].
Torresani C. Clarithromycin: a new perspective in rosacea treatment. Int J Dermatol. May 1998;37(5):347-9. [Medline].
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].
Keywords
ocular rosacea, rosacea, adult acne, inflammatory keratitis, corneal ulceration, corneal perforation
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, Staff Physician, Department of Ophthalmology, Emory University
Evan S Loft, MD 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.
Medical Editor
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.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman 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
CME Editor
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.