IF A PATIENT was to present with a complaint of red, irritated eyes that had been waxing and waning for quite some time, your primary diagnosis, depending on time of year, might be dry eye disease (DED) or allergic conjunctivitis. However, take a step back from the slit lamp and look your patient in the face and even have them remove their mask, as it may help reveal a different culprit: rosacea.

Rosacea is a chronic, inflammatory dermatologic condition affecting more than 16 million Americans characterized by flushing, erythema, telangiectasias, papules, and/or pustules on the central face, most commonly the cheeks, forehead, chin, and nose (National Rosacea Society, 2023). It typically presents in the third to fifth decades of life (Vieria et al, 2012). However, it can affect patients of all ages (even children) and has a waxing and waning presentation. While it is more common in individuals who have fair skin and those of Northern European descent, it can be present in all ethnicities (Elewski et al, 2011).

Ocular rosacea is a subtype that is present in up to 58% to 72% of patients (Redd and Seitzman, 2020). Although dermatologic rosacea generally affects more women than men, ocular rosacea affects both sexes equally (Vieira et al, 2012).

Ocular rosacea is frequently underdiagnosed, particularly because 90% of patients have ocular symptoms that mirror that of DED but without any or very subtle skin involvement (Vieria et al, 2013). In 20% of the cases, ocular signs may even precede characteristic skin involvement (Ghanem et al, 2003).

No definitive laboratory test exists for rosacea/ocular rosacea. The diagnosis is based on clinical observation and patient history, which can be essential because some features, especially that of the skin, may not be visually evident or present at the time of the patient’s visit.

Patients who have ocular rosacea may experience eye and eyelid redness; eye discomfort (foreign body sensation, burning, dryness, or itching); tearing; photophobia; and blurry or fluctuating vision. The hallmark signs of ocular rosacea include meibomian gland dysfunction, eyelid margin keratinization, and especially eyelid margin telangiectasias (Figure 1). Additional signs of manifestation are conjunctival injection, eyelid erythema, blepharitis, Demodex, punctate keratitis, recurrent hordeola, or chalazia. Patients who have more severe ocular rosacea can develop corneal neovascularization, subepithelial infiltrates, scarring, and ulceration, which can lead to corneal perforation causing significant visual impairment (Vieira et al, 2012).

It’s apparent that there is a strong association with ocular rosacea and DED. All patients who have rosacea should be asked about ocular symptoms. If they are asymptomatic, it’s only a matter of time before they do become symptomatic (Sinikumpu et al, 2022). Patients should be educated on the importance of an annual eye exam because ocular rosacea leads to a decline in meibomian gland morphology causing meibomian gland loss (Machalińska et al, 2016), which leads to evaporative dry eye and can greatly affect ocular morbidity and quality of life.

Diabetic patients should have an annual eye exam and all primary care providers are aware of its impact on ocular health. However, one could argue that dermatologists should be referring all rosacea patients for an eye exam as well, given the high association with meibomian gland dysfunction and DED. It is our job as eyecare providers to educate not only our patients on this association, but also our local dermatologists, because recognition of the condition is a key part to its management. CLS

References

1. National Rosacea Society. If You Have Rosacea, You’re Not Alone. rosacea.org/patients/information . Accessed Mar. 14, 2023.
2. Vieira AC, Höfling-Lima AL, Mannis MJ. Ocular rosacea--a review. Arq Bras Oftalmol. 2012 Oct;75:363-369.
3. Elewski BE, Draelos Z, Dréno B, Jasen T, Layton A, Picardo M. Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group. J Eur Acad Dermatol Venereol. 2011 Feb;25:188-200.
4. Redd TK, Seitzman GD. Ocular rosacea. Curr Opin Ophthalmol. 2020 Nov;31:503-507.
5. Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed. J Am Acad Dermatol. 2013 Dec;69:S36-S41.
6. 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 Apr;22:230-233.
7. Sinikumpu SP, Vähänikkilä H, Jokelainen J, Tasanen K, Huilaja L. Ocular Symptoms and Rosacea: A Population-Based Study. Dermatology. 2022;238:846-850.
8. Machalińska A, Zakrzewska A, Markowska A, et al. Morphological and Functional Evaluation of Meibomian Gland Dysfunction in Rosacea Patients. Curr Eye Res. 2016 Aug;41:1029-1034.