treatment plan
Ocular Rosacea — The Dermatologic Connection
BY WILLIAM L. MILLER, OD, PHD, FAAO

Practitioners often associate cases of recurrent conjunctival injection and symptomatic ocular irritation with dry eye syndrome or allergic ocular disease. But careful attention to the facial skin may reveal the real culprit — rosacea. Rosacea is a chronic cutaneous syndrome affecting the regions of the face with waxing and waning of the disease process.

The prevalence of rosacea in the United States is around 13 million or approximately 1 in every 20 individuals. It can occur in any ethnicity, but more frequently in patients of northern European descent or in those who have fair skin. It affects more females than males (3:1) and occurs typically between the fourth and sixth decades of life. Rosacea patients who have ophthalmic rosacea may range from 3 percent to 58 percent.

Signs and Symptoms

Common primary facial signs to look for include telangiectasia, flushing (transient erythema), nontransient erythema, papules, pustules, edema and rhinophyma. Any one of the first four signs indicates rosacea. Patients may also experience burning or stinging, red elevated skin plaques and dry scaly skin.

Ophthalmic signs, which may occur before dermatological signs in up to 20 percent of patients, can include conjunctival hyperemia and lid inflammation. Patients may also suffer from frequent bouts of hordeola and chalazia. Severe cases may demonstrate corneal vascularization, corneal infiltrates and episcleritis/scleritis.

Rosacea is classified into four subtypes and one variant with each ranging from mild to moderate to severe (Wilkin et al, 2002). Ocular rosacea falls under subtype 4, following subtypes erythematotelangiecatic, papulopustular and phymatous. Patients who have ocular rosacea exhibit interpalpebral hyperemia, foreign body sensation, burning or stinging, dryness, itching, photophobia, blurred vision, telangiectases of conjunctiva and lid margin and/or lid and periocular erythema. Patients may also have blepharitis, conjunctivitis or irregular eyelid margins. An inflamed eyelid with telangiectasia may be a key determinant for diagnosis.

Treatment Options

Treatment of the ocular manifestations of rosacea will target the eyelid and ocular surface. Treat blepharitis and meibomian gland dysfunction with lid hygiene and oral antibiotics such as doxycycline or minocycline (100 mg, b.i.d.). Over-the-counter tear supplements can prevent ocular surface drying. Cyclosporine (Restasis, Allergan) may help alter aqueous tear production and target ocular surface inflammation.

Fit affected contact lens wearers into low-water-content lenses, preferably silicone hydrogels, which move well on the eye. A more frequent replacement schedule minimizes contact lens surface deposits.

You can coordinate with your patient's physician or dermatologist to provide other systemic treatments. In addition to the oral antibiotics mentioned earlier, metronidazole (Flagyl) in a topical cream or gel can be used. For female patients who are pregnant, topical clindamycin (Cleocin) is a suitable alternative to the cyclines and metronidazole. Other second line treatments include Accutane or topical tretinoin. Patients can prevent facial flushing by avoiding triggers such as sunlight and alcohol or through the use of low dose clonidine (Catapres; 0.05mg b.i.d.). Azelaic acid (Finacea) as a 15% gel is approved to combat facial redness and pustules. 

To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #132.

Dr. Miller is on the faculty at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.