Rosacea ocular

Chronic inflammatory eye involvement of the rosacea symptom complex, which may or may not be accompanied by skin changes. In about 20% of rosacea patients, this symptomatology is a harbinger of rosacea. In 25 to 50% of affected individuals, ocular rosacea occurs concurrently with skin symptoms.

Ocular rosacea is observed in about 20% (6-18% according to other authors) of patients with skin symptoms. In primary ocular rosacea, skin lesions are absent or only discretely developed. This form can already occur in childhood.

Corresponds to the age of manifestation of rosacea (around 80% of patients are older than 30 years). The average age at clinical presentation is 50 years (Saá FL et al. (2021). In around 20% of patients, the ocular symptoms occur several years after the skin changes. Women were more frequently affected than men.

Euphrasia officinalis(eyebright)-containing eye drops (WALA Euphrasia®).

The clinical symptoms are accompanied by redness and inflammation of the lid margin and the tarsal and bulbar conjunctiva (blepharitis, conjunctivitis sicca). Furthermore, foreign body or dryness sensation, burning sensation and increased lacrimation are reported. Not infrequently, these symptoms are associated with eyelid edema or even edema of the periorbital region.

Severe forms are associated with disturbances of the tear film and visual disturbances (sensitivity to light, blurred vision).

An unfavorable prognosis applies to rosacea ceratitis, since it can lead to ulceration, possibly to perforation and blindness.

Note: There is no correlation between the severity of cutaneous rosacea and the extent of ocular symptomatology. In rare cases, isolated involvement may occur, making it difficult to assign to rosacea.

Bacterial, viral (e.g. Herpes simplex virus) or allergic conjunctivitis.

In ocular rosacea, the risk of chalazion (hailstones) or conjunctivitis is increased. As a consequence of chronic blepharoconjunctivitis , corneal ulcers may occur in combination with corneal vascular neoplasms.

Interdisciplinary dermatologic-ophthalmologic therapy approach: The therapy of the disease includes a local treatment of the eyelid changes directly as well as a general treatment of the underlying disease. Standard measures today are:

Warming and cleansing of the eyelids: Warming the eyelids for at least 4-5 minutes liquefies the fatty secretion of the meibomian glands and can thus be massaged out of the eyelids. It is important that the heating is carried out efficiently and that the massage of the eyelids is carried out according to the course of the glands towards the eye (upper eyelid from top to bottom, lower eyelid from bottom to top). Remove crusty deposits from the edges of the eyelids using e.g. vegetable oils, physiological saline solution or boiled water and cotton buds. The procedure should be carried out twice a day over a period of > 3 months.

Antibiotics: Antibiotics (tetracyclines, acythromycin, etc.) are not only useful in cases of obvious infection, but also in cases of chronic, non-infectious progression due to additional anti-inflammatory and lipolytic mechanisms of action. Efficacy has been proven in particular for systemically applied tetracycline derivatives. This therapy must also be used for at least 3 months in order to achieve a lasting improvement in the situation.

Note: Patients with ocular rosacea should avoid the use of isotretinoin, as this can worsen the eye symptoms (dryness symptoms).

Anti-inflammatory medication: In the case of severe inflammatory changes, eye drops and ointments containing glucocorticoids are used. These almost always lead to a rapid improvement during application, but also to recurrences after discontinuation. Due to side effects with long-term use (cataracts or glaucoma), glucocorticoid externa should only be used temporarily on the eye. Alternative: e.g. ciclosporin eye drops in suitable carrier systems (NRF formulation).

Tear substitutes: Tear substitutes can be used to symptomatically alleviate the symptoms of dry eyes, which are often present at the same time. Of the many preparations available, an unpreserved preparation should be used if used more than 2-3 times daily (hyaluronic acid-containing tear substitute: GenTeal, Hyalo-Vision. Tear drops containing carbomer: Thilo-Tears®; nature: eye drops containing Euphrasia officinalis (eyebright) (WALA Euphrasia).

Tetracyclines: Efficacy has been demonstrated, particularly for systemically applied tetracycline derivatives. The drug of choice is doxycycline. Alternatively, minocycline is recommended. This therapy must also be used for at least 3 months to achieve a sustained improvement in the situation. Permanently, 50mg doxycycline every 2nd day is sufficient to suppress ocular inflammation.

Note: Patients with ocular rosacea should refrain from using isotretinoin as it may worsen ocular symptoms (dryness symptoms).

De Marchi SU et al (2014) A 79-year-old woman presented with a 10-year history of red eye, photophobia, burning and foreign body sensation, recurrent conjunctivitis blepharitis and episodes of blurred vision. She also reported symptoms of dry eye, but the Schirmer test had revealed a normal amount of tears. Over the past year, facial flushing and flushing phenomena were noted in response to consumption of spicy foods and alcoholic beverages. The patient had been examined by general practitioners, ophthalmologists, dermatologists and allergists and had received several topical treatments, which were ineffective.

Erythema and telangiectasia appeared on the nose, cheeks, glabella and forehead, as well as bilateral conjunctivitis-blepharitis. Teleangiectasias were visible on the inflamed eyelid margins and the bulbar conjunctiva was hyperemic with dilated, tortuous blood vessels. A diagnosis of erythematotelangiectatic rosacea with ocular rosacea was made.

Therapy: The patient was treated with oral doxycycline. The initial dose of 100 mg was continued for 2 weeks, followed by a maintenance dose of 50 mg/day for a total of 2 months of therapy. No further episodes of conjunctivitis-blepharitis occurred during the 6 months of follow-up.

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