Ocular Rosacea

Unfortunately, the nuanced and nonspecific nature of ocular rosacea signs and symptoms often leads to underdiagnosis and oversight.

Ocular Rosacea

Ocular rosacea stands as a chronic inflammatory ailment primarily stemming from heightened sensitivity to common environmental stimuli. 

Ocular rosacea is characterized by the emergence of telangiectatic vessels, especially along the lid margin, and inflammation within the ocular region, contributing to a persistent redness of the eyes. This condition often coincides with dry eye, meibomian gland dysfunction (MGD), and blepharitis, further intensifying irritation and causing damage to the ocular surface and eyelids.

The occurrence of ocular rosacea may overlap with facial rosacea or manifest in isolation. The condition also extends to the sebaceous glands which can result in the emergence of dilated telangiectatic vessels, prone to flushing, leading to the distinct reddish complexion often associated with rosacea.

Left untreated, the condition can lead to scarring, adversely impacting both aesthetics and tissue functionality.

Who gets Ocular Rosacea? 

Approximately 5% of the global population grapples with rosacea, with a staggering 16 million Americans navigating this condition.

Although rosacea predominantly emerges during middle age, with 80% of patients being 30 or older, its peak incidence occurs between the ages of 40 and 59. Ocular rosacea exhibits a balanced prevalence among both genders. While less common, even children can be affected by this condition. 

Notably, facial rosacea diagnosis skews more towards females, possibly influenced by differential care-seeking behaviour. Furthermore, rosacea showcases a higher prevalence among Caucasians, particularly those with fairer skin, although its reach extends across all racial backgrounds.

Rosacea Variants

The Expert Committee of the National Rosacea Society classifies rosacea into four subtypes along with one variant:

1. Erythematotelangiectatic
2. Papulopustular
3. Phymatous
4. Ocular rosacea
5. Granulomatous variant

Among these, the ocular rosacea subtype directly targets the eyelids and ocular surface.

Aetiology of Ocular Rosacea

The enigma of ocular rosacea traces back to an imbalance in our immune response, centred around Toll-like receptor 2 (TLR2) within skin keratinocytes.

When environmental factors, like extreme temperatures, stimulate TLR2, it kickstarts a chain reaction, heightening KLK5 activity and cathelicidin production. Cathelicidins, acting as inflammation igniters, also play a role in angiogenesis.

This surge in cathelicidin leads to increased vascular endothelial growth factor (VEGF) expression, giving rise to the telangiectatic vessels and the characteristic flushed appearance of rosacea.

But this immune symphony has more players. MMP-8 and 9, interleukin-1α and β, ICAM-1, and TNF-α are part of the inflammation orchestra.

Intriguingly, ocular rosacea patients show reduced levels of Phospholipase A2 Group IIA, a potent antimicrobial protein against Gram-positive bacteria.

Pathophysiology of Ocular Rosacea

While the mechanisms of rosacea are clear, its root cause remains debated.

Candidates include: 

1. Helicobacter pylori
2. Staphylococcus epidermidis
3. Parasitic mites Demodex folliculorum and Demodex brevis.

Demodex stands out, residing in hair follicles and sebaceous glands. When their numbers surge, issues like blepharitis and MGD can arise. Rosacea patients often harbour more Demodex, with these mites potentially sparking immune responses linked to the condition. Moreover, Demodex frequently accompanies eyelid inflammation, a common companion of ocular rosacea.

An intriguing twist suggests Demodex might be carriers for other infectious agents, like Bacillus olenorium, potentially the true instigators of rosacea's inflammation.

In the riddle of ocular rosacea, understanding TLR2, cathelicidins, and Demodex's intricate roles brings us closer to unravelling this complex condition.

Severity Grading of Ocular Rosacea

The Ocular Rosacea Grading Scale, developed by the international ROSacea COnsensus (ROSCO) expert panel, offers a comprehensive assessment of ocular rosacea severity by evaluating tissue involvement.

• Mild 
• Gentle blepharitis along with the presence of lid margin telangiectasia (visible blood vessels).
• Mild-to-moderate 
• Encompasses blepharoconjunctivitis.
• Moderate-to-severe 
• Encompasses blepharokeratoconjunctivitis.
• Severe 
• Encompasses sclerokeratitis and/or the concurrent presence of anterior uveitis (inflammation of the anterior part of the eye).

This innovative grading system provides a precise framework to assess and categorise ocular Rosacea, aiding in accurate diagnosis and treatment planning.

Ocular rosacea commonly manifests bilaterally, impacting both eyelids and the entire ocular surface. Among the primary indications of ocular rosacea, frequently reported as the prevailing concern, is the presence of eye redness.

The redness stems from the expansion of telangiectatic blood vessels and concurrent inflammation affecting the eyelids and ocular surface. Notably, the regions prominently affected encompass the lid margin and the intrapalpebral conjunctiva. The outcome of these effects is a visibly injected and watery appearance in the eyes, imparting a distinctive look. 

Both rosacea and its ocular variant exhibit a pattern of relapse and remission, accompanied by acute flare-ups triggered by environmental factors. This leads to variations in the intensity of signs and symptoms. Over time, rosacea tends to progress, underscoring the importance of early intervention. If left untreated, the condition may exacerbate. Monitoring and managing ocular rosacea can be key to preventing its deterioration.

Ocular Rosacea and Dry Eyes

Ocular rosacea frequently exhibits a strong correlation with dry eye, particularly dry eye linked to blepharitis and MGD.

Studies suggest that a significant 92% of ocular rosacea cases involve MGD, underscoring its importance.

Chronic inflammation often gives the lid margin a distinct notched or scalloped outline. Notably, in rosacea, there is an abnormal increase in epithelial cell turnover, leading to a build-up of dead epithelial cells on the lid margin. This build-up can physically block the meibomian gland opening, hindering proper meibum secretion and eventual significant meibomian gland loss if left untreated.

• Blepharitis indicators
• Collarettes and debris present on eyelashes can point towards potential Demodex blepharitis.
• MGD-related complications
• An unstable tear film, laden with debris and saponification, contributes to a shortened tear breakup time (TBUT). Aspects like recurrent hordeola and chalazion, frequently occurring in ocular rosacea

It's crucial, however, to distinguish these lid lesions from sebaceous gland carcinoma, which has the potential to mimic recurrent hordeola or chalazion.

Ocular Rosacea Keratitis 

One of the most concerning aspects of ocular rosacea is its potential to give rise to Rosacea Keratitis, a condition that can pose a serious threat to vision.

Notably, approximately one-third of ocular rosacea cases involve corneal complications.

• The onset of Rosacea Keratitis is typically marked by the emergence of superficial punctate keratitis, commonly observed on the lower part of the cornea.
• As the condition advances, peripheral neovascularization and inflammatory subepithelial infiltrates develop, further complicating the situation.
• If not promptly addressed, these subepithelial infiltrates can progress into ulcers, potentially leading to vision-threatening scarring or even corneal perforation. 

Treatment for Ocular Rosacea:

Ocular rosacea, though not curable, can be effectively managed through various treatment approaches. 

Optometrists play a crucial role in understanding and implementing these treatment options for patients. Addressing both the primary symptoms of ocular rosacea and the concurrent dry eye conditions is essential. Treatment protocols for ocular rosacea often align with those used for managing dry eye, making a comprehensive approach pivotal for success.

1. Identification and Avoidance of Triggers

An inherent feature of rosacea, including ocular rosacea, is hypersensitivity to environmental stimuli, triggering inflammation and dilation of blood vessels. This response accentuates facial flushing and exacerbates discomfort in ocular rosacea patients. Identifying and steering clear of specific irritants is central to any effective treatment strategy.

• Environmental Factors 
• Extreme heat 
• Extreme cold
• Wind and sun exposure
• Emotional Triggers
• Stress
• Anger 
• Embarrassment 
• Physiological 
• Strenuous exercise
• Dietary Triggers
• Caffeine 
• Chocolate 
• Alcohol
• Dairy products 
• Hot beverages
• Spicy food
• Pharmaceutical and Supplements
• Nasal and topical (cutaneous) steroids
• Beta-blockers 
• Amiodarone 
• Niacin
• Vitamin B6 and B12
• Certain Cosmetics 

2. Topical Cutaneous Treatments

Prominent among cutaneous treatments for rosacea are:

• Metronidazole
• Azelaic acid

These anti-inflammatory agents, available in various formulations, are usually applied twice daily. While mainly intended for facial rosacea, metronidazole can also alleviate eyelid inflammation.

Additional topical treatments encompass brimonidine tartrate gel, oxymetazoline hydrochloride cream, and ivermectin cream, applied once daily.

Coordinating with a dermatologist ensures the most effective application of these therapies.

3. Lubricants 

Lubricants offer palliative relief for ocular rosacea symptoms, primarily due to their lubricating properties.

Lipid-based artificial tears are particularly suitable as they restore disrupted lipid components of the tear film, often seen in meibomian gland dysfunction.

These are advised for regular use, usually dosed four times daily, with the switch to preservative-free variants if usage exceeds this frequency.

Read our top eye drop recommendations here 'Top Eye Drops for Dry Eyes'

4. Effective Lid Hygiene

Ocular rosacea often causes the accumulation of inflammatory debris and bacterial biofilm on the lid margin, perpetuating chronic inflammation, scarring, and keratinization.

Therefore, a fundamental aspect of ocular rosacea management is maintaining lid hygiene.

• Tea tree oil, known for its anti-inflammatory and antimicrobial properties, is a potent option. Lid scrubs containing tea tree oil can be employed, ensuring eradication of Demodex mites, a common concern in ocular rosacea.
• Hypochlorous acid, exhibiting antibacterial and anti-inflammatory attributes, beneficial for addressing bacterial issues often seen in ocular rosacea.

• Microblepharoexfoliation treatments like BlephEx® (Alcon), NuLids, and NuLids PRO (NuSight Medical).

• Effectively tackles these issues by removing inflammatory debris, reducing bacterial load, and minimizing Demodex presence—a known contributor to ocular conditions.
• Performing debridement before thermal pulsation treatments optimizes meibomian gland function, improving expressibility and enhancing treatment outcomes.

5. Focus on Meibomian Gland Dysfunction

Given the heightened epithelial cell turnover in rosacea, dead cells can amass on the lid margin, potentially obstructing meibomian glands. This exacerbates MGD and increases the risk of hordeolum and chalazion development.

Therefore, a fundamental aspect of ocular rosacea management is unblocking clogged meibomian glands. 

• Warm compresses followed by lid massage are common conservative approaches.
• However, the temperature achieved by most warm compresses is unlikely to reach that required to completely liquefy the oil, so this treatment is primarily palliative.

Aelo Heated Eye Masks, is preferable to “homemade” compresses, such as a washcloth or rice-filled sock, as our masks retain heat for a longer duration and the level of heat is more controlled.

• In-office thermal pulsation procedures
• Intense Pulse Light (IPL) Therapy, LipiFlow® or iLux®
• Omega-3 supplements 
• Complementing these treatments with omega-3 supplements enhances meibum quality.

6. Oral Antibiotics for Inflammation

Oral antibiotics particularly tetracyclines like doxycycline, are widely used in managing ocular rosacea.

• Doxycycline
• Encompassing both anti-inflammatory and anti-angiogenic effects. The mechanism behind its inflammation-reducing prowess involves the inhibition of MMP-9 and MMP-70, alongside the suppression of VEGF.
• Exhibits favourable impacts on MGD and dry eye.
• Doxycycline contributes to enhancing the quality of meibum.

The formulation of doxycycline and the frequency of dosing for treating ocular rosacea vary depending on the provider, as there is no universally agreed-upon standard dose or treatment duration.

Typically, an initial loading dose followed by a lower maintenance dose regimen is used. This involves 40-100mg QD-BID for 1-2 weeks, then 20-40mg QD for 1-4 months. Some prefer ongoing low doses, while others opt for intermittent use.

In treating rosacea, doxycycline is prescribed below its antibacterial dose (20-40mg) for anti-inflammatory effects. This suits ocular rosacea treatment, enhancing tolerability and reducing antibiotic resistance risk.

Doxycycline is avoided in pregnancy, nursing, and <7-year-olds due to bone/teeth effects. Educate patients about side effects like GI issues and photosensitivity.

• Azithromycin 
• 500mg daily for 2 weeks is an alternative for non-responsive cases.
• Other options (tetracycline, minocycline, isotretinoin)
• These have limitations. Tetracycline needs frequent dosing, minocycline lacks evidence and has more side effects, isotretinoin worsens ocular rosacea with adverse effects.

7. Topical Antibiotics

• Erythromycin 0.5% ophthalmic ointment 
• Typically administered before sleep
• This application aims to reduce bacterial presence on the eyelids and ensure continuous lubrication overnight.
• Nonetheless, a subset of patients might experience irritation with erythromycin. In such instances, alternative topical ointments and gels can be employed to enhance nocturnal comfort.
• Azasite (azithromycin 1%) ophthalmic solution
• The utilization of Azasite on the eyelid margin has demonstrated efficacy in enhancing meibomian gland dysfunction while also reducing inflammation.
• Azithromycin exhibits excellent tissue penetration and sustained effectiveness, prompting a treatment regimen that commences with an initial loading dose, succeeded by a lower maintenance dosage.
• There are two potential dosing regimens to consider:
• Twice daily (BID) for 2 days, followed by once daily (QD) for 30 days
• Once nightly (QHS) for 2 weeks, followed by twice-weekly maintenance doses.

8. Topical Anti-inflammatories 

• Topical corticosteroids
• Effectively tackles acute inflammation, but long-term use poses risks like intraocular pressure spikes and cataract development. Choosing a gentler steroid is wise for treating inflammation linked to ocular rosacea, adjusting potency as needed.
• Initial inflammation relief or acute flare control typically involves using 0.5% loteprednol etabonate two to four times daily for 1 to 2 weeks, potentially extending to 4 weeks for persistent cases.
• Topical cyclosporine 
• For chronic inflammation, consider alternatives like Xiidra, Cequa, and Restasis.
• Administered twice daily, these drops offer safe, extended use.

9. Diet and Supplements 

• Omega-3 fatty acids
• A wealth of studies underscores the advantages of incorporating omega-3 fatty acids into one's diet due to their notable anti-inflammatory effects.
• The efficacy of omega-3 supplements can vary considerably, emphasizing the importance of opting for a high-quality, re-esterified triglyceride-based product.
• For optimal results, patients are strongly advised to select a supplement featuring a 3:1 EPA to DHA ratio, and a minimum total of 2 grams of combined EPA and DHA, as research demonstrates that this specific composition distinctly enhances MGD management

10. Intense pulsed light (IPL) therapy

Intense pulsed light (IPL) offers a non-invasive procedure using high-intensity polychromatic light on the skin (400 to 1200nm). IPL's exact mechanisms involve photobiomodulation, using light energy to trigger anti-inflammatory responses. It promotes anti-inflammatory cytokine production while reducing proinflammatory factors.

Treatment covers the periocular area, spaced 3 to 4 weeks apart over four sessions, with additional maintenance as needed.

For MGD, it liquefies gland-clogging meibum and eradicates Demodex, bacteria, and telangiectatic vessels, improving both cosmetic appearance and inflammation.

Formerly off-label, IPL's decade-long role in dry eye and MGD treatment gained FDA approval for on-label use, particularly with the OptiLight™ IPL device (Lumenis). IPL's comprehensive approach cements it as an ideal choice for ocular rosacea treatment.

11. Other Treatments 

• Vasoconstrictive agents
• Lumify (0.025% brimonidine tartrate), stand out by constricting veins and reducing redness, while also potentially curbing inflammation and VEGF production.
• This makes them a multi-faceted solution for ocular rosacea management, unlike products with rebound redness.
• Punctal plugs
• Not suited for ocular rosacea due to the risk of prolonged inflammation
• Amniotic Membranes 
• For severe corneal cases, these offer anti-inflammatory and healing benefits, proving valuable for rosacea keratitis.

Frequently Asked Questions

Can I still wear contact lenses with ocular rosacea?

Although contact lenses can be worn by these patients with success, it is advisable to recommend against wearing lenses during periods of acute inflammation. Ideally, they should refrain from using lenses until their condition is well-controlled. This caution is important because wearing contact lenses might inherently contribute to inflammation.

Moreover, it's essential to ensure the optimal health of the ocular surface before introducing contact lenses to ocular rosacea patients. The recommendation strongly leans towards fitting ocular rosacea patients with daily disposable lenses, which not only enhances comfort but also promotes the health of the ocular surface. In specific instances, discontinuing contact lens use entirely might become necessary if it becomes evident that lens usage exacerbates their condition or triggers issues like increased neovascularization.