The Occurrence Of Ocular Rosacea

In addition to having unsightly acne-like facial effects, a large percent of rosacea sufferers have eye symptoms. Eighty-nine percent of 2,010 rosacea sufferers responding to the survey indicated that they also experienced discomfort or redness of the eyes in varying degrees. However, of those with eye symptoms, only 27% reported that they had been diagnosed with ocular rosacea. Only 24% said they were treated for the condition.

"Although many people may not connect their eye symptoms with a skin disorder, this is quite common with rosacea and needs to be more widely recognized by the general public and health professionals alike," said Dr. Guy Webster. Webster is associate professor of dermatology at Thomas Jefferson University Medical College in Philadelphia. "Because of the eye symptoms, sometimes an ophthalmologist will be the first to notice rosacea and point the patient to a dermatologist."

Visually, an eye affected by rosacea often appears simply to be watery or bloodshot. Some ocular rosacea patients experience no eye discomfort. But many feel as if there is a foreign body or something gritty in their eyes.

They may also have a dry, burning or stinging sensation.
In severe cases, ocular rosacea may include:
Swollen blood vessels (conjunctival infection)
Inflammation of the eye or eyelid (blepharitis)
Inflammation of the iris (iritis)
Inflammation of the whites of the eyes (episcleritis)
A cyst due to plugging of glands under the eyelids (chalazion)
Loss of vision, in rare instances
A sty-an inflammation of the sebaceous glands of the eyelids-is also common in rosacea sufferers. It is believed to be potentially related to the condition.

"One of the reasons ocular rosacea may often go undetected is the fact that these symptoms tend to develop separately from the facial symptoms of the disorder," Dr. Webster noted. Thirty-eight percent of the survey respondents said their ocular symptoms developed after their facial symptoms. Seventeen percent said their ocular symptoms occurred before facial symptoms. Only 15% reported that their eye and facial symptoms appeared at the same time.
Dr. Webster pointed out that ocular rosacea has been found in up to 58% of rosacea patients in clinical studies. It seems to worsen during the winter months. This may be a result of the frequent gusty winds and cold temperatures.

The good news is that medical therapy appears to be widely effective in improving the symptoms. Of the survey respondents who had been diagnosed and treated for ocular rosacea, 90% said their condition had improved.

Once diagnosed, a physician will usually prescribe a combination of treatments for ocular rosacea tailored to the individual. This may include local and systemic therapy, as well as cleansing and tearing agents, all of which may be adjusted over time. The facial symptoms of rosacea are usually treated with oral and topical antibiotics. This is often followed by long-term therapy with the topical antibiotic alone to maintain remission.

The Diagnosis And Management of Rosacea

Rosacea is a chronic recurrent inflammatory skin condition affecting primarily the central areas of the face with ocular involvement in 50 per cent of patients. It is relatively common and it has been estimated to affect approximately 14 million people in the US.
The cause of rosacea has not yet been established. Genetic factors, environmental, vascular, inflammatory factors, bacteria and micro-organisms have all been considered as possible contributors or causes.
The majority of patients with rosacea are aged between 30 to 60 years old. It affects more women than men. The prevalence of rosacea is highest among fair-skinned individuals, especially those of Celtic origin, and has not been diagnosed as often in dark skinned individuals although recent research indicates that darker skinned individuals may be more commonly affected than previously believed.
As rosacea affects the face, and because of the common misconception that the development of rosacea may be linked with alcohol abuse, it has a significant psychosocial impact and therefore diagnosis and management are critical.

The diagnosis of rosacea is based on the clinical features. Symptoms and signs include facial flushing, persistent centrofacial erythema, inflammatory papules and pustules, telangectatic vessels and hypertrophy of the sebaceous glands with fibrosis. Ocular changes can range from mild blepharitis and conjunctivitis through to sight threatening keratitis. Typically, rosacea follows a pattern of remission and flares of symptoms. There is often an overlapping of symptoms, however, in the majority of patients a particular clinical picture of rosacea dominates.
This allows rosacea to be classified into four subtypes:
Subtype 1 is termed Erythrematotelangiectatic.  Patients in this group have troublesome flushing and persistent central facial erythema. Telangectatic vessels are present. Flushing is exacerbated by spicy foods, alcohol, hot drinks, temperature change, exercise and emotional stress. The differential diagnosis includes lupus erythematosus, chronic actinic damage, and photosensitivity. If flushing is severe carcinoid syndrome, phaeochromocytoma and polycythaemia may need to be considered.
. Papulopustular rosacea (subtype 2) is characterised by erythematous dome-shaped papules and small pustules on the central face with a background erythema. Sometimes oedema can occur. In contrast with acne, patients with rosacea do not have comedones (whiteheads and blackheads) and scarring of the skin does not occur.
 Phymatous rosacea is subtype 3. It is rare and most commonly seen in men. It results from hyperplasia of the sebaceous glands and connective tissue and is characterised by distorted thickened skin and surface nodules. It is most commonly seen on the nose (rhinophyma).
Ocular rosacea (subtype 4) is common but is frequently overlooked. It has been estimated to be present in 50 per cent of patients with rosacea. Symptoms range from mild irritation to burning and stinging to blurred vision. Patients can have blepharoconjunctivitis, chalaia, hordeola, and very rarely keratitis, with potential visual loss.
These subtypes are useful in the guidance of therapy. The severity of each subtype can be graded as 1(mild), 2 (moderate) or 3 (severe).
Management of rosacea includes avoidance of exacerbating factors, medications to suppress the inflammatory lesions and the use of surgery or laser therapy for phymatous disease and telangectasias. Treatment is guided by the predominant subtype of rosacea the patient has.
Patients with rosacea have sensitive skin, so mild cleansers and emollients are advised. All patients with rosacea should apply sunscreens daily to prevent the development of facial photodamage that will exacerbate the redness of rosacea. Patients should attempt to identify aggravating factors to flushing and avoid these, and be advised that effective cosmetic coverage can neutralise erythema. Accurate patient information can be accessed via groups such as the National Rosacea Society () and American Academy of Dermatology () that have websites.
Erythematotelangectatic rosacea is difficult to treat. Where telangiectatic vessels are significant pulsed dye laser therapy, which causes selective photothermolysis, can be employed. This results in coagulation of the superficial vessels without associated dermal damage.
Topical and systemic antibiotics are the principal treatments for papulopustular rosacea. Topical metronidazole is both antibacterial and anti-inflammatory, and application twice daily results in less erythema and a reduction in inflammatory lesions. Topical metronidazole should be used with caution in women of child bearing age who are not taking oral contraception as it potentially can be absorbed and has mutagenic side effects.
Sodium sulfacetamide (antibacterial) and sulfur (keratolytic) topically can be used. Azelaic acid (antibacterial, anti-inflammatory) top- ically is comparable in efficacy to topical metronidazole. Topical erythromycin (antibacterial; anti-inflammatory) is another effective therapy.
Systemic agents, with or without concurrent topical treatment, are indicated in moderate to severe (grades 2 and 3) papulopustular rosacea.
Systemic agents such as oxytetracycline, doxycycline, erythromycin and minocycline, are most frequently used. Treatment should be for four to 12 weeks. Once systemic treatments are ceased, topical therapy is then continued to maintain a remission.
Rhinophyma is uncommon. Grades 2 and 3 rhinophyma can be effectively treated with surgical excision, electrosurgery or CO2 – laser therapy.
Ocular rosacea is common and usually mild. It is treated with good eyelid hygiene and warm compresses, artificial tears and topical application of metronidazole gel to the eyelid margins. Grades 2 and 3 may require treatment with systemic antibiotics. Referral to an ophthalmologist should be made if symptoms are persistent or severe.
Summary:
• Rosacea is a common condition with a significant psychosocial impact.
• Rosacea can be classified into subtypes which guide effective therapy.
• All patients should apply sunscreen daily and, where possible, avoid exacerbating factors.
• Erythematotelangiectatic rosacea is best managed with sun protection and possibly carbon dioxide laser treatment for prominent telangectasias.
• Papulopustular rosacea is usually treated with topical agents and/or systemic antibiotics.
• Phymatous rosacea is uncommon. Effective therapies include surgery and laser therapy.
• Ocular rosacea can be managed with eyelid hygiene, artificial tears and topical metronidazole. Persistent or severe symptoms should prompt referral to an ophthalmologist.
• Patient can access accurate information on websites such as the National Rosacea Society or the American Academy of Dermatology .

Dr Maeve McAleer, Dermatology Senior House Officer, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin

Ocular Rosacea's Effect on Sight

While red, teary or scratchy eyes might sometimes be shrugged off as simple irritation from harsh winter weather, these may actually be warning signs of ocular rosacea, a potentially serious condition that many people do not associate with a skin disorder.
"The effects of rosacea on the eyes may easily be overlooked because they often develop after, and sometimes before, the disorder affects the skin," said Dr. Bryan Sires, associate professor and acting chair of ophthalmology at the University of Washington. "In most cases, ocular rosacea is a mild, irritating condition, but it can develop into a permanently debilitating one -- including loss of vision -- without proper care."
Although as many as 58 percent of rosacea patients have been found to have ocular symptoms in clinical studies, he noted that the condition may be easily controlled if diagnosed and treated before it becomes severe.
An eye affected by rosacea often appears to be watery or bloodshot. Patients may feel a gritty or foreign body sensation in the eye, or have a dry, burning or stinging sensation.
Dr. Sires added that in the majority of ocular rosacea patients, beyond mild irritation there is a feeling of fullness in the eyelid. This is often the result of thickened secretions of the meibomian or Zeis glands along the eyelid margin. The fatty secretions help to avoid evaporation of the watery layer of the tears. The plugging of these glands may lead to dry eye or styes, both common manifestations of ocular rosacea.
"Severe symptoms result when the cornea becomes infected," he said. "These patients have a deep boring pain. At this point, an aggressive treatment approach is necessary to avoid the need for a more invasive procedure like corneal transplantation."
Left untreated, patients with severe ocular rosacea could endure scarring within the eyelid, vision loss from corneal ulcers and potential loss of the eye if an ulcer progresses beyond the cornea.
Ocular rosacea is diagnosed by an overall examination of both the facial skin and eyes. Ophthalmologists also frequently use a biomicroscope, which allows the detection of tiny visible blood vessels along the eyelid margin and any plugging of the meibomian glands -- both signs of ocular rosacea.
Treatment for ocular rosacea is typically a combination of local and systemic therapy as well as cleansing and tearing agents, all of which may be adjusted over time.
For mild cases, patients are often instructed to use warm compresses several times a day on the eyelids. Lid hygiene may include gentle cleansing with a Q-Tip and baby shampoo. For moderate cases, topical medications may be prescribed, along with eye drops for lubrication.
"For more severe cases, patients are placed on oral antibiotics such as doxycycline," Dr. Sires said. "This is at regular doses for a two-week period and then at a maintenance dose for several months thereafter."
As with facial rosacea, ocular rosacea patients are also encouraged to identify and avoid any lifestyle or environmental factors that may trigger or aggravate their individual condition. Common trigger factors include emotional stress, hot or cold weather, wind, spicy food, alcohol, heated beverages and many others.