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 Table of Contents  
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 168-172

Rosacea and eye

Department of Ophthalmology, Dr. Yashwant Singh Parmar Government Medical College, Sirmour, Himachal Pradesh, India

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Lalit Gupta
Department of Ophthalmology, Dr. Yashwant Singh Parmar Government Medical College, Nahan, Sirmour, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_105_17

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Rosacea is a multisystem disorder and to the general practitioner, involvement of the skin is what comes to the mind first of all. A broad array of ocular manifestations encompasses this condition and ocular examination is as essential as examination of other part of body when rosacea is talked about. Here, we present an in depth review of ocular rosacea so that adequate knowledge is shared among all the doctors regarding [email protected] subject.

Keywords: Manifestations, ocular, rosacea

How to cite this article:
Gupta L, Chauhan A. Rosacea and eye. Kerala J Ophthalmol 2017;29:168-72

How to cite this URL:
Gupta L, Chauhan A. Rosacea and eye. Kerala J Ophthalmol [serial online] 2017 [cited 2023 Feb 8];29:168-72. Available from: http://www.kjophthal.com/text.asp?2017/29/3/168/224284

  Introduction Top

Rosacea is a syndrome of unknown etiology involving the skin and eye. Rosacea is a relatively common disorder of the “blush area” of the skin of face, which has been known for centuries. The lack of knowledge concerning the clinical correlation between ocular and cutaneous rosacea is an example of the price we have to pay for the increasing specialization of medicine.[1] A review of the early literature by Holloway (1910) gives art (1864) the credit for first associating the ocular and cutaneous manifestations of the condition.[2] In the middle ages, it was known as “Gutta Rosacea”, and the clinical appearances to which it gave rise are referred to in the writings of Chaucer and Shakespeare. At first, it was confused with Acne vulgaris, and today, the old term Acne Rosacea has been replaced by the term Rosacea.[3]

Rosacea has been indelibly linked with the bulbous nose and “gin blossoms” of comedian and alcohol aficionado W. C. Fields, but the condition actually results from a disparate assortment of stimuli acting in concert on a genetically susceptible host. Although descriptions suggestive of rosacea harkens back to biblical times, modern diagnosis and treatment seemed intertwined with pharmaceutical and advertising industries. Patients in our cosmetically conscious society flock to physicians' offices and demand topical salves in lieu of considering requisite behavior modification.[4]

Rosacea is well recognized as a chronic cutaneous disorder primarily of the convexities of the central face (cheeks, chin, nose, and central forehead), often characterized by remissions and exacerbations. Based on present knowledge, it is considered a syndrome or typology, encompassing various combinations of such cutaneous signs as flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and rhinophyma. In most cases, some, rather than all of these stigmata appear in a given patient.[5]

Although rosacea is now recognized as a common skin disorder, it has been misunderstood and misdiagnosed for centuries. Rosacea is now recognized as a distinct medical condition that requires early diagnosis and appropriate management to minimize patient discomfort and psychological distress.[6]

In patients who have both skin and ocular manifestations, 20% of patients first develop their ocular manifestations, 53% of patients develop their skin lesions first while 27% develop both manifestations simultaneously.

The disease develops gradually. Initially, patients may be unaware of their condition and thus not seek medical attention, thinking the redness, flushing, and occasional papules or pustules of rosacea are simply normal flushing, adult acne, or sunburn. However, early recognition is important because untreated rosacea can lead to disfigurement and potential vision loss. There is no specific test for rosacea, but its characteristic appearance, cutaneous distribution, discrete course, typical target population, and response to various therapies make accurate diagnosis possible.[7]

History of exacerbation by the sun exposure, stress, cold weather, hot beverages, sudden emotions (laughter or embarrassment), alcohol consumption, or certain foods helps to determine the diagnosis.[8]

Among dermatologists ocular Rosacea may be designated as an orphan disease. It generally goes unrecognized, undiagnosed, undertreated, and underreported.[9] Many years ago, Duke Elder, the doyen of academic ophthalmology, opined that ocular rosacea was a common disease but could not offer any solid figures regarding its prevalence. Dermatologists and ophthalmologists have recorded widely differing estimates because they do not see the same patients. Dermatologists focus their attention on skin while ophthalmologists focus on eyes. Both of them use the monocular vision while treating the patient. Systematic epidemiological studies are totally lacking. The ocular symptoms are so nonspecific that the condition remains under diagnosed. If both ophthalmologists and dermatologists examine the same patient for both ocular and skin manifestations, the detection rate of ocular rosacea will increase and early measures could be initiated to save eyes.

Rosacea may be overlooked in nonwhites because of low index of suspicion or because skin pigmentation results in atypical presentation.[7] Individuals with good pigmentation ability showed tendency to decreased occurrence of Rosacea.[10] It affects up to the 10% of the population, especially fair-skinned people.[4] Rosacea has an inverse relationship with increasing skin pigmentation [11] and skin types I and II are more often affected than darker skin types.[12]

Ocular complications and late manifestations of Rosacea may occur in a disproportionate number of dark skin people.[8],[13],[14] Ocular involvement ranges from blepharitis and conjunctival hyperemia to sight-threatening problems such as corneal neovascularization, thinning ulceration, and perforation. Treatment with tetracycline and topical steroids was as effective as in whites.[13],[14]

Rosacea occurs most commonly in adult life between ages of 30 and 50 years, more in women, but it has been assumed to the fact that woman may consult physicians more frequently and early than men.[10] The decade of prevalence in ocular Rosacea is 51–60 years, then for cutaneous Rosacea (40–50 years).[9],[15] Rosacea without ocular involvement involves women twice as often as men, but cases with ocular manifestations are about evenly distributed between the two sexes or show only slight female preponderance,[9] with the exception of episcleritis, which was only seen in females, and iritis only in men.[1] Ocular Rosacea is usually bilateral,[3] but may be unilateral.[10]

The presence of blepharitis, keratoconjunctivitis, or episcleritis may suggest diagnosis in a child with mild facial eruption.[16]

Rosacea tends to begin in childhood as common facial flushing, often in response to stress. A diagnosis beyond this initial stage of rosacea is unusual in the pediatric population. If a child is identified with the intermediate stage of rosacea, consisting of papules and pustules, an eye examination should be performed to rule out ocular manifestations. It may be beneficial to recognize children in the early stage of rosacea; however, it is uncertain if prophylactic treatment is necessary.[17]

Some cases in late childhood and teenagers have been reported in literature including  Meibomian gland More Details dysfunction (MGD) or Rosacea keratoconjunctivitis which may be misdiagnosed as a viral or bacterial infection like in adults, where associated cutaneous changes are uncommon.[9],[18],[19],[20]

Ocular rosacea has been called a common disease, but its incidence in an ophthalmic population is not known.[3] In addition, the frequency with which ocular signs and symptoms are found vary widely.[1],[2] Ocular findings are grouped as either minor or major, nonsight to sight-threatening. Minor complications are much more common. The prevalence of ocular involvement in patients with rosacea has been reported as low as 3%[1] to as high as 58%.[6] Symptoms frequently go undiagnosed because they are too nonspecific.

Duke-Elder reported that blepharitis in every case of rosacea eventually appear and sometimes spread to conjunctiva assuming diffuse hyperemic type and rarely nodular conjunctivitis. Nodular episcleritis near limbus and rosacea keratitis with marginal ulcer occur as an extension of Rosacea. Conjunctivitis frequently accentuated in lower quadrants. This may be associated with punctate keratitis and later on subepithelial infiltrates develop. Numerous scars, horseshoe-shaped, or tongue-shaped, develop with apex directed toward the center of cornea.[3] Vitritis has been associated with rosacea and can be the rare association.[9]

Jenkins et al. reported that the patients of rosacea have burning out of proportion to the clinical signs of disease.[9],[21]

A common presentation is a patient with mild conjunctivitis with soreness, grittiness, lacrimation, foreign body sensation, pain, or redness. The reported signs are telangiectasia and irregularities of the lid margins (81%), MGD (78%), blepharitis (65%), conjunctival hyperemia (45%), keratoconjunctivitis sicca (26%), stromal keratitis with peripheral neovascularization (16%), superficial punctate keratitis (15%) usually in the inferior half of cornea, chalazion (10%), cicatrizing conjunctivitis (9%), episcleritis (8%), recurrent epithelial erosions (5%), corneal ulcer (5%), iritis (2%), scleritis (0.7%), conjunctival granulomas (0.7%), and phlyctenular conjunctivitis (0.7%). Corneal thinning has also been described.[15]

Wise reported that the ocular signs are much more prevalent in patients from ophthalmologic clinics when compared patients from dermatologic clinics.[22] Wise reported that the most common ocular signs in patients with rosacea from ophthalmologic clinic were blepharitis (93%), conjunctival hyperemia (80%), and corneal vascularization and infilterates (67%). Jenkins et al.[21] reported conjunctival hyperemia (86%), telangiectasia of the lid margin (63%), blepharitis (47%), and superficial punctate keratopathy (41%).[23] Ghanem et al. reported that MGD was the most common sign (85.2%), telangiectasia of the lid margin (53.4%), blepharitis (44.3%), and interpalpebral hyperemia in (85.2%), diffuse bulber hyperemia was observed only in 9% of the cases.[24] Ghanem et al. concluded, in a study after comparing patients from ophthalmologic and dermatological clinics, that the major and most easily observable ocular problems in Rosacea patients are lid-related manifestations most common being meibomian gland dysfunction, telangiectasia, blepharitis, chalazion, and others.[24]

The results as observed by Akpek et al. were lid margin telangiectasia (81%), MGD (78%), and blepharitis in 65% patients.[15]

Zengin et al. concluded that MGD is an important feature of ocular rosacea. Lower Schirmer's values and short tear break up times (TBUT) in ocular rosacea might be a consequence of MGD. Treatment with tetracycline seems to improve TBUT values. Decreased tear secretion in patients with ocular rosacea would seem to be a result of structural changes secondary to MGD, and short break up time might be due to abnormal meibium composition.[25]

Mcculley and Sciallis, found a decrease in TBUT in 26 patients with blepharitis, 9 (35%) of whom were found to have cutaneous rosacea subsequently. After the meibomian glands were expressed manually, normalization of TBUT occured.[26]

Shimazaki et al. reported that MGD is the major cause of dry eye as well as tear deficiency leading to ocular discomfort and abnormality in the ocular surface.[27] An excessive evaporation of tears is present in patients who showed MGD evidenced by meibomian gland drop out. The patients who show MGD and especially those with low tear production as evidenced by Schirmer's test, have an increased risk of dry eye developing through increased evaporation which leads to ocular surface changes.[28]

Duke Elder stated that a mild blepharitis or frequently a blepharoconjunctivitis appears in the course of most cases of rosacea; it is more common but much less important than the corneal complications which may arise. Its significance lies in the fact that, in addition to the occurrence of chalazia with which it is frequently associated, it is in a large number of cases forerunner of keratitis. The blepharitic tendency occurs essentially in seborrheic people; indeed, it may be said to take place of acne vulgaris in such persons. It starts with the hyperemia of the lid-margins which persists with intermissions until a state of chronic stasis and congestion is reached. Such a state leads eventually to disturbances of secretions and congestion of the sebaceous glands of the lid-border, and at this stage frank symptoms of blepharitis appear. Its most characteristic symptom is its obstinacy; the persistent erythema, scale formation, and the development of pustules and the furuncles leads eventually to permanent thickening, hypertrophy, and loss of the lashes.[29]

Telangiectasia of the eyelid margin routinely occurs and tends tn be parallel the cutaneous flushing rather than the extent of skin eruptions.[11],[30]

Kligman reported that a man with rhinophyma almost always shows signs and symptoms of ocular Rosacea.[7]

Patrinely et al. described the clinicopathological features of papular form of granulomatous acne rosacea of the eyelids. There were symmetrical periorbital, papular eruptions more concentrated on the lower eyelids.[31]

Ajith et al. reported a case of granulomatous rosacea mimicking eyelid dermatitis, where patient of eyelid dermatitis was initially being treated as a case of allergic contact dermatitis, due to topical ophthalmic medication, but did not improve, finally diagnosed as a case of granulomatous rosacea on histopathological examination and patient improved on oral doxycycline 100 mg bid and topical metronidazole gel (0.75%) for local application twice daily for 8 weeks.[25]

King et al. have reported a case of rosacea presenting as extensive squamous hyperplasia of the meibomian duct within the eyelid along with other signs of ocular and cutaneous rosacea.[32]

Albert et al. reported conjunctival granulomas in patients with rosacea, showing similar response to facial and ocular manifestations with antibiotic therapy, confinement of the granulomas to the bulbar conjunctiva, and no definite evidence of other systemic disease, and suggested that rosacea should be included in the differential diagnosis of conjunctival granulomas.[33]

Chen and Crosby [34] reported that periorbital edema might be an initial presentation of rosacea. They described three rosacea cases in whom periorbital odema was an initial manifestation, and they were refractory to the conventional treatments for rosacea.

Chronic rosacea Lymphodema involving the eyelids is a rare complication, and when involves upper lid, presents as ptosis. Lai et al. have reported one case of rosacea lymphoedema [35] and Bernardini et al. have reported two cases. Six similar cases have been reported previously in dermatologic literature; all of which have been treated medically without satisfactory results. Surgical debulking should be considered in these patients.[36]

Ravage et al. have concluded that the presence of chronic cicatrizing conjunctivitis affecting mainly the upper lids previously thought to be unique to trachoma can be associated with ocular Rosacea.[37]

Akpek et al. reported that the most common corneal finding in rosacea to be punctate epithelial keratopathy usually confined to inferior half of cornea.[3],[15]

Starr and Macdonald [2] have reported that, 33% of corneas showed some signs of rosacea in his study, and the earliest corneal involvement was infiltration in superficial stroma with a “lucid interval” between the grayish haze and leashes of invading blood vessels, with a number of corneas showed infiltration in the deeper layers of stroma, and thinning of overlying cornea. Focal corneal abscesses with secondary bacterial infection produced the severest symptoms of keratoconjunctivitis and led to permanent scarring.

Borrie,[1] on the other hand, has reported keratitis as the most common ocular manifestation, accounting for over 85% of all the cases in his study. Wise has reported corneal infiltrates and neovascularization in 67% and the results of study by Jenkins et al.[21] are 41%.

Duke Elder [3] was of opinion that the first appearance of rosacea keratitis is a marginal vascular infiltration, an extension of rosacea conjunctivitis, frequently accentuated in the lower quadrant, may be associated with punctate epithelial keratitis sometimes combined with subepithelial opacities. Subepithelial infilterates develops next near to limbus and progress mainly in lower half, later surface breaks down leaving marginal, or central corneal ulcer with resulting gross impairment of vision. Numerous tounge-shaped or horseshoe-shaped ulcers develop with apex directed toward the center of cornea.

Lee et al. have reported a case of ocular and cutaneous rosacea with denderitic keratopathy where herpes simplex was ruled out with negative viral cultures and PCR testing, with marked improvement on systemic therapy for rosacea and emphasized that ocular rosacea should be considered in the differential diagnosis of atypical denderitic lesions of cornea.[38]

Dursun et al. in their study reported that chronic ocular rosacea can produce inferior corneal thinning and high astigmatism with some features of keratoconus. The inferior pattern of thinning may be related to chronic exposure of the inferior cornea to inflammatory and matrix degradation fectors in inferior tear meniscus. As the extracellular matrix in this region of cornea is lost, the inferior cornea may be thin and steepened mimicking keratoconus.[39]

Lemp et al. using Schirmer-I testing, as a measure of aqueous tears creation, found a significantly greater prevalence of dry eyes in patients of ocular rosacea than normal controls. He also suggested that the incidence of rosacea and keratoconjunctivitis sicca is high in general population, particularly, from 4th to 6th decade and both conditions may be associated.[40]

Gudmundsen et al. concluded that dry eyes frequently occur in rosacea. In their study of rosacea patients, 56.3% had <8 mm of strip wetting compared with 25% of control patients (P < 0.02). Of rosacea patients, 40.6% had <5 mm of strip wetting compared with 18.75% of controls (P < 0.10).[41]

Koçak-Altintas et al. found that Schirmer tests and tear film break up time (TBUT) were significantly lower in patients with ocular rosacea than in normal controls (P < 0.05) and concluded that patients with ocular rosacea not only had decreased tear production but also tear lnstability. Ocular surface epithelium had significant degeneration in patients compared with normal controls.[42]

As the pathogenesis of disease is unknown, and no undisputed Histopathological or laboratory hallmarks of the disease exists, the diagnosis rests largely on a constellation of clinical signs. It is the lack of criteria to choose to make a definitive diagnosis on the part of ophthalmologists which is responsible for underdiagnosis.[9]

All the patients attending to either of departments, dermatology, and ophthalmology should have complete ophthalmologic and dermatologic evaluations, so that both ocular and dermatologic manifestations can be treated at the earliest, and complications can be avoided.

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  References Top

Borrie P. Rosacea with special reference to its ocular manifestations. Br J Dermatol 1953;65:458-63.  Back to cited text no. 1
Starr PA, Macdonald A. Oculocutaneous aspects of rosacea. Proc R Soc Med 1969;62:9-11.  Back to cited text no. 2
Duke Elder S. Diseases of outer eye. In: System of Ophthalmology. Vol. 8. Part-I. St. Louis: CV. Mosbey; 1965. p. 534-45.  Back to cited text no. 3
Landow K. Unraveling the mystery of rosacea. Keys to getting the red out. Postgrad Med 2002;112:51-8.  Back to cited text no. 4
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Burns T, Breathnach S, Cox N, Griffiths C. Cutaneous photobiology. In: Rook's Text Book of Dermatology. Vol. 2. UK: Blackwell Science; 2004. p. 24. 9-10.  Back to cited text no. 13
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Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: Patient characteristics and follow-up. Ophthalmology 1997;104:1863-7.  Back to cited text no. 15
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Drolet B, Paller AS. Childhood rosacea. Pediatr Dermatol 1992;9:22-6.  Back to cited text no. 18
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Ghanem VC, Mehra N, Wong S, Mannis MJ. The prevalence of ocular signs in acne rosacea: Comparing patients from ophthalmology and dermatology clinics. Cornea 2003;22:230-3.  Back to cited text no. 24
Ajith C, Dogra S, Radotra BD, Handa S. Granulomatous rosacea mimicking eyelid dermatitis. Indian J Dermatol Venereol Leprol 2005;71:366-5.  Back to cited text no. 25
[PUBMED]  [Full text]  
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Kanski JJ. The dry eye. In: Kanski JJ, Menon J editors. Clinical Ophthalmology: A Systemic Approach. India: Butterworth Heinemann; 2003. p. 56-61.  Back to cited text no. 30
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King W, Hofman RJ, Jakobic FA. Extensive squamous hyperplasia of meibomian duct in acne rosacea. Arch Ophthalmol 1994;112:160-1.  Back to cited text no. 32
Albert DL, Brownstein S, Jackson WB. Conjunctival granulomas in rosacea. Am J Ophthalmol 1992;113:108-10.  Back to cited text no. 33
Chen DM, Crosby DL. Periorbital edema as an initial presentation of rosacea. J Am Acad Dermatol 1997;37:346-8.  Back to cited text no. 34
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