Rosacea is a chronic inflammatory disease of the skin that causes acne-like bumps and redness of the face and the neck. Sometimes rosacea manifests with eye problems called ocular rosacea.
The intensity of the symptoms varies from person to person. Ocular rosacea affects up to 60% of people who have rosacea. Adults are primarily affected at the ages of 30 and 50.
The cause of rosacea is not known. The flushing (erythema) of the face and neck usually develops as a result of exposure to temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment (for example heated shops and offices during the winter), hot baths or saunas, intake of certain foods or drinks. Some medications can also contribute to the development of this condition. Hereditary predisposition is also possible.
It is suggested that some microorganisms may also be involved in the pathogenesis of ocular rosacea:
- Demodex mites cause inflammation of the eyelids that results in anterior blepharitis;
- Some bacteria may lead to eye problems in rosacea as antibiotics are effective in the treatment of ocular rosacea. Scientists believe that bacterial lipases release toxic free fatty acids and glycerides from the substances secreted by meibomian glands (a kind of sebaceous gland at the rim of the eyelids, responsible for the prevention of evaporation of the eye’s tear film);
- Ocular tissues may be damaged by the upregulation of metallomatrix protein-9 (MMP-9).
Meibomian glands get inflamed and obstructed that leads to reduced tear film lipid layer, tear film instability, tear hyperosmolarity.
Ocular rosacea is usually the first sign of rosacea, but can also develop later as the disease progresses. In some cases, ocular rosacea may occur without the damage to the skin. It is believet that those whose face becomes red from time to time are more likely to develop ocular complications.
Skin rosacea is more likely to affect females, although the incidence of ocular rosacea is similar for both genders.
Ocular rosacea affects the eyelids causing blepharitis, cornea leading to keratitis and conjunctiva (conjunctival hyperaemia).
A person experiences itching, dryness and redness of the eyes, sensitivity to light (photophobia), blurred vision, loss of eyelashes, grittiness and stinging in the eyes. Granulomatous inflammatory lesions around meibomian glands called chalazions may be found.
An affected person has a burning sensation of the eyes, he/she may complain of the feeling as if some foreign body is under the eyelid for example an eyelash. The eyes as well as the nose and cheeks appear to be red. On the white part of the eye dilated small blood vessels may be detected (bloodshot eyes). Excessive tearing (watery eyes) may be present. The eyelids are swollen and reddish.
It is important to remember that the severity of the eye symptoms doesn’t match to the severity of skin lesions.
Dryness of the eyes along with blepharitis lead to the defect of cornea (corneal ulcer) that may result in vision loss. Corneal damage can include pannus formation (a layer of vascular fibrous tissue) and phlyctenules (corneal nodules). In severe cases rarely iris and sclera are involved and iritis, episcleritis and scleritis occur.
Examination of the eyes, eyelids and the skin of the face and the precise analysis of the complaints, symptoms and medical history will help to verify the diagnosis.
There is no treatment to cure the condition as it tends to be chronic, although medication will help to relieve the symptoms and lead to a temporary remission.
Lid hygiene should be kept (dilute baby shampoo, dilute bicarbonate solution or proprietary preparation can be applied with Q-tips or any sterile cotton swab).
First-line therapy of rosacea is systemic tetracyclines (doxycycline). Oral antibiotics are usually administered for 6-112 weeks. Pulse therapy with Azithromycin is also effective. Blepharitis may be treated with erythromycin, polimyxin B, methronidazone etc.
Topical anti-inflammatory therapy includes topical non-steroidal anti-inflammatory medications, topical steroids and ciclosporin.
To improve the function of meibomina glands dietary supplements with Omega-3 fatty acids are recommended.
Oral retinoids (isoretonin) can be used in low doses.
Doctor may put thin rods into the glands to renew their permeability (so-called “probing”. Use of artificial tears and warm compresses may be helpful to relieve the pain.
If the cornea is damaged keratoplasty may be needed to restore the vision.
People who have ocular rosacea should avoid stress, intense activities, exposure to sunlight and extreme weather conditions (heat, cold, wind etc.). Dietary restrictions regarding alcohol, caffeine and spicy foods are necessary.