Q: I have a few patients whom I suspect have ocular rosacea—but, they don’t show any overt signs of acne rosacea. They experience a refractory blepharoconjunctivitis. How should I proceed?  

A: Take a very thorough history if you suspect a diagnosis of rosacea. “In such cases, 80% of the diagnosis comes from the history,” says Carlo Pelino, O.D., of Pennsylvania College of Optometry at Salus University. Ocular rosacea can occur in isolation or as part of generalized rosacea, and ocular signs and symptoms can sometimes precede skin involvement.

When taking this history, determine if the patient has any of the predisposing factors of rosacea, related conditions, or if he or she has noticed any flare-ups resulting from a trigger. “A targeted history will allow you to determine what can trigger the patient’s flare-ups,” says Joseph Pizzimenti, O.D., associate professor at Nova Southeastern University College of Optometry. Several other conditions can mimic skin rosacea, including seborrheic dermatitis, lupus erythematosus and chronic topical corticosteroid therapy. Common triggers of rosacea: smoking, spicy food, alcohol, and prolonged exposure to sunlight.1 Tomatoes, chocolate, citrus fruit, exposure to extreme hot or cold temperatures, and increased levels of stress and anxiety may also cause the patient’s rosacea to flare up.1

“From the doctor’s standpoint, when we diagnose rosacea, the trigger is the critical point,” Dr. Pelino says. “We can prescribe medicine. But, overall, the education about these triggers is the important take-home information.”

But, what actually causes rosacea? “There is a fundamental abnormality in the sebaceous glands of the body—primarily, those of the face,” says Dr. Pizzimenti. “An inflammatory reaction seems to be initiated, which results in abnormal secretion of the meibomian glands of the eyelids and general abnormalities in sebaceous gland secretion elsewhere on the face. We see papules and pustules as well—it’s basically an inflammatory breakout.” In the early stages of rosacea, vascular changes may appear. Look for the hallmark telangiectasia—prominent dilated blood vessels—in the central portion of the face. Also, some systemic indicators and related conditions can help you narrow your diagnosis. “There is a hereditary genetic component,” says Dr. Pelino. “And Helicobacter pylori may also be implicated.”

Recent research points to another organism’s possible role in the pathogenesis of rosacea.2Demodex folliculorum mite infestation is believed to be part of the pathogenic mechanism of rosacea,” says Dr. Pizzimenti. Researchers believe that, in patients with papulopustular rosacea, this mite may stimulate the inflammatory response.2 A bacterial cause of the disease has also been postulated, but not proven. “Examine the lid and lashes carefully—you might find D. folliculorum there,” says Dr. Pelino. “I try to educate patients that this is a cause, so they’ll need to use lid scrubs.”

Make sure your patients understand that rosacea is a lifelong condition, with flare-ups and periods of remission. “This is a non-curable skin disease, so patient education about the triggers is very important,” says Dr. Pelino. “Most people think the term ‘acne rosacea’ is acne, but it’s not. Adults don’t outgrow rosacea.”

Also, be clear when explaining the ocular consequences of rosacea. “The main ocular consequence is ocular surface inflammatory disease—including dry eye syndrome,” says Dr. Pizzimenti. “The others involve primarily the eyelids—e.g., anterior or posterior blepharitis. Rosacea patients are also more susceptible to bacterial conjunctivitis. And, corneal disease due to severe drying or infection is also a possibility.”

Patients need to understand and comply with a care regimen. “I start by suggesting warm compresses, followed by lid scrubs with pre-moistened pads. Mild to moderate lid disease in rosacea responds well to a topical steroid-antibiotic combination drug (such as Zylet or Tobradex) or an antibiotic with anti-inflammatory properties such as AzaSite (topical azithromycin). In severe ocular rosacea, topical treatments may be less effective— I find that these patients do better when I put them on oral medication earlier,” says Dr. Pizzimenti. “Rosacea is a systemic condition, so more often than not, it requires systemic treatment.”

Consider Oracea (Galderma Laboratories), a time-release formulation of doxycycline specifically indicated for acne rosacea. Make sure to develop your management plan based on each patient’s needs. “Treatment depends on what I see during the exam,” says Dr. Pelino. “Consider referring the patient to a dermatologist for treatment with oral drugs if you’re not comfortable prescribing them. Some O.D.s will start with a regimen doxycycline. Or, if there’s evidence of meibomian gland dysfunction, start the patient on a regimen of hot compresses and lid massage.”  

“Another method that helps: Place the patient on an omega-3 regimen,” Dr. Pizzimenti adds. “It demonstrates anti-inflammatory properties and can help normalize the tear film.” This therapeutic regimen might even include the use of Restasis (cyclosporine, Allergan) for those with severe dryness and corneal disease.  

1. Pizzimento JJ, Pelino CJ. Soothe the burn of ocular rosacea. Rev Optom. 2008 Jun 15;145(6):43-9.
2. Lacey N, Delaney S, Kavanagh K, Powell FC. Mite-related bacterial antigens stimulate inflammatory cells in rosacea. Br J Dermatol. 2007 Sep;157(3):474-81.