Ocular Rosacea – A Complete Guide

Ocular rosacea, also known as rosacea keratitis is an inflammation that causes redness, burning, and itching of the eyes. It often develops in people who have rosacea, a chronic skin condition that affects the face. Sometimes ocular rosacea is the first sign that you may later develop facial rosacea.

It ranges from foreign body sensation, minor irritation, dryness, and blurry vision to severe ocular surface disruption and inflammatory keratitis. Patients frequently describe a gritty feeling, and they commonly experience conjunctivitis and blepharitis. Other ocular findings include lid margin and conjunctival telangiectasia, corneal infiltrates, punctate epithelial erosions, chalazion and hordeolum, corneal scars, eyelid thickening, eyelid crusts and scales, corneal ulcers, and vascularization. Sight-threatening disease is rare with rosacea.

Meibomian gland dysfunction (MGD) and blepharitis are commonly present along with ocular rosacea, resulting in further ocular surface irritation and lid damage.

Symptoms may include:

• red, burning, or watering eyes
• a persistent feeling like something is stuck in your eye
• redness and swelling on the eyelids and at the base of the eyelashes

There is no cure for ocular rosacea but it is manageable. There are so many treatments available for ocular rosacea, so let’s look into it:

Finding your trigger:

• Environmental factors
  • Extreme heat
  • Extreme cold
  • Wind and sun exposure
• Emotional triggers
  • Stress
  • Anger
  • Embarrassment
• Physiological stimuli
  • Hard exercise
  • Saunas
  • Hot baths
• Dietary triggers
  • Caffeine
  • Chocolate
  • Alcohol
  • Dairy products
  • Hot beverages
  • Spicy food
• Pharmaceuticals and supplements
  • Nasal and topical (cutaneous) steroids
  • Beta-blockers
  • Amiodarone
  • Niacin
  • Vitamins B6 and B12
• Certain cosmetics especially those containing alcohol, witch hazel, fragrances

Two of the most commonly used cutaneous rosacea treatments are metronidazole and azelaic acid.

Artificial tears offer quick relief and can prevent irritation when used prophylactically. Lipid-based Artificial tears are the best choice for ocular rosacea, as they help stabilize the lipid component of the tear film which is often disrupted by Meibomian gland dysfunction. They are also capable of reducing inflammatory factors present in the tear film.

If a patient needs to use artificial tears more than four times a day, a preservative-free artificial tear is strongly recommended, or else they would risk developing surface toxicity due to repeated preservative exposure. However, if a patient is using artificial tears more frequently than four times a day, that is an indication additional treatments may be needed to manage their discomfort. Refresh Optive Mega-3 (Allergan) is an excellent choice for use in ocular rosacea, as it is a preservative-free lipid-based artificial tear.

Artificial tears:

• Fusidic acid gel (daily 1 to 2 times application on eyelids) limited data available for efficacy
• Metronidazole 0.75% gel (daily 1 to 2 times application on eyelids) limited data available for efficacy
• Cyclosporine 0.05% eyedrops, (one drop every 12 hours) limited data available for efficacy

Note: do not use typical redness reducer eye drops intended to treat occasional bloodshot eyes. These can make ocular rosacea symptoms worse.

Lid hygiene is another important step in ocular rosacea treatment. Tea tree oil has anti-inflammatory and antimicrobial properties, as well as the ability to eradicate Demodex, making it an ideal treatment for ocular rosacea.

Another option is hypochlorous acid. Hypochlorous acid is an antiseptic that is naturally produced by the immune system to neutralize bacterial toxins and exhibits anti-inflammatory properties. Hypochlorous acid also works well in reducing the overgrowth of Staphylococcus epidermidis, which can contribute to blepharitis and tear film saponification observed in ocular rosacea.

Special eyelid cleaning products like Blephadex, Cliradex, or even baby shampoo diluted 1:1 with warm water may be recommended.

Given the presence of Meibomian gland dysfunction (MGD) in the majority of cases of ocular rosacea, addressing the eyelids is a core element of a comprehensive management plan. Treatment may involve using warm compresses followed by lid massage to free clogged meibum present in the meibomian glands. However, the temperature achieved by most warm compresses is unlikely to reach that required to completely liquefy the oil, so this treatment is primarily palliative.

While warm compresses are helpful in treating Meibomian gland dysfunction (MGD), they should be used cautiously in the presence of ocular rosacea, as the heat from the compress may exacerbate any present inflammation. If a patient can use compresses without issue, they can be performed daily or whenever needed. A mask-like compress is specifically made for the treatment of Meibomian gland dysfunction (MGD), such as a Dry Eye Relief Mask (EyeEco) or a Bruder Moist Heat Eye Compress (Bruder). It is much better to use rather than homemade compresses, such as a washcloth or rice-filled sock, as these masks retain heat for a longer duration and the level of heat is more controlled.

Patients can also perform blink exercises consisting of several complete blinks followed by a forceful blink. These blinking exercises can encourage proper blinking mechanics and behavior, which are critical for normal meibum secretion and tear film renewal. Blinking exercises can be recommended as often as every 20 minutes, or as frequently as is practical.

More advanced treatment of Meibomian gland dysfunction (MGD) involves in-office thermal pulsation procedures, such as LipiFlow (Johnson & Johnson), TearCare (Sight Sciences), or iLux (Alcon). Thermal pulsation treatment has been shown to improve signs and symptoms of Meibomian gland dysfunction (MGD). During this period patients can take an omega-3 supplement if they are not already doing so, as omega-3 fatty acid supplementation improves the quality of the meibum produced.

Microblepharoexfoliation, such as BlephEx (Alcon), can be used as an adjunct to thermal pulsation procedures or as a standalone therapy. In blepharitis, bacterial biofilm and inflammatory debris can build up on the lid margin, causing chronic inflammation that results in keratinization and scarring. This debris can worsen MGD and make the patient prone to a hordeolum and chalazion development. Debridement of the lid margin with microblepharoexfoliation removes inflammatory debris, reduces the bacterial load, and decreases the number of Demodex present. Performing debridement prior to thermal pulsation also ensures the terminal ends of the meibomian glands are patent, allowing for improved gland expressibility and better treatment outcomes.

Oral antibiotics, specifically tetracyclines can help with ocular rosacea. The most commonly used oral tetracycline is doxycycline due to its better tolerability, lower side effect profile, and less frequent dosing when compared with other tetracyclines. 

In cases where doxycycline is contraindicated, azithromycin is a good alternative. Azithromycin is a macrolide antibiotic that can also decrease inflammation and improve symptoms of ocular rosacea when dosed with 500 mg every day for two weeks.

Other oral medications that have been used in the treatment of rosacea and ocular rosacea include minocycline, tetracycline, and isotretinoin (Accutane). These are not usually recommended as tetracycline’s short half-life requires more frequent dosing, minocycline has little evidence to support its use in treating rosacea and carries more side effects, and while isotretinoin may be helpful for facial rosacea, its side effects include conjunctivitis, blepharitis, and meibomian gland destruction which can all worsen ocular rosacea.

Topical corticosteroids are excellent for treating acute inflammation but are not ideal for long-term ocular rosacea management due to cataract development and the risk of intraocular pressure spikes. A soft steroid with low side effects, such as loteprednol etabonate, is a good choice for treating OR flares, however, stronger steroids may be necessary depending on the degree of inflammation present.

It is worth noting topical steroid use itself can trigger flares in rosacea patients. Although this is typically seen with cutaneous and nasal preparations, it is another reason steroids are best suited for treating acute episodes rather than long-term inflammation control.

Other anti-inflammatory medications, such as Cequa (0.09% cyclosporine ophthalmic solution), Xiidra (5% lifitegrast ophthalmic solution), and Restasis (0.05% cyclosporine ophthalmic emulsion) are better suited for the management of chronic inflammation associated with ocular rosacea. All three drops are dosed two times a day and can safely be used long-term.

Topical preparations of tacrolimus have also shown promise in managing ocular rosacea and associated blepharitis and MGD.

Topical antibiotics can also be useful therapies in the treatment of ocular rosacea. Erythromycin 0.5% ophthalmic ointment applied every night can be used as a nocturnal therapy to decrease the bacterial burden on the lids and provide lubrication throughout the night. However, some patients may find erythromycin irritating in which case other topical ointments and gels can be utilized for nighttime comfort.

A novel treatment involves the off-label use of topical azithromycin. The application of Azasite (azithromycin 1% ophthalmic solution) to the lid margin has been shown to improve MGD and decrease inflammation. Azithromycin penetrates tissue well and has a prolonged duration of action, so treatment is started with a loading dose followed by lower maintenance doses.

Dietary supplements play an important role in ocular rosacea management. Many studies have demonstrated the benefits of omega-3 fatty acid consumption, including anti-inflammatory effects. Omega-3 supplementation is necessary for MGD treatment as it improves the signs and symptoms of the condition. However, not all omega-3 supplements are of the same quality, which can significantly impact efficacy. Therefore, it is strongly recommended that patients use a high quality, re-esterified, triglyceride-based omega-3 supplement with a 3:1 EPA to DHA ratio and at least 2 grams of combined EPA and DHA to achieve the optimal benefits of supplementation, as this specific formulation has been shown to effectively improve MGD.

The use of probiotics can potentially alleviate rosacea signs and symptoms, and a high-fiber diet may also be helpful.

Intense Pulsed Light (IPL) is a very common procedure that is used in the treatment of ocular rosacea. IPL has several potential mechanisms of action that address inflammation, erythema, and MGD, as well as bacterial and Demodex blepharitis, making it one of the most promising treatments for ocular rosacea. When used for OR and dry eye, treatment is applied to the periocular region from tragus to tragus, with shields in place over the eyelids or corneas. The standard protocol involves four total treatments, typically spaced three-four weeks apart. However, additional treatments can be added if necessary, and many patients require maintenance treatments in the future.

In the context of ocular surface and dry eye disease, IPL reduces inflammation and improves the signs and symptoms of dry eye and MGD. It is thought to improve inflammation on the ocular surface by stimulating the production of anti-inflammatory cytokines while decreasing proinflammatory factors. In terms of MGD, it has been proposed that the energy delivered by the light is great enough to liquefy meibum in clogged glands thereby improving the quality of secretions. IPL is also capable of eradicating Demodex, as pigment in the mite’s exoskeleton absorbs light energy produced by IPL leading to its destruction. Additionally, IPL decreases the bacterial load present on the lid margins. Cosmetically, IPL improves the appearance of facial and ocular erythema by destroying telangiectatic vessels.

The OptiLight IPL device (Lumenis) recently received FDA approval for the treatment of MGD and dry eye making this use of IPL an on-label indication.

Eye drops for ocular rosacea

Other treatments in the management of OR include vasoconstrictive agents. Although oral antibiotics, lid hygiene, and topical anti-inflammatories can reduce erythema associated with inflammation, they do not address redness due to the perpetually dilated state of telangiectatic vessels. Vasoconstrictors are helpful in addressing this source of redness, which is especially useful in improving cosmetic appearance.

Lumify (0.025% brimonidine tartrate ophthalmic solution) is a highly selective α2-adrenergic agonist, which causes constriction of the conjunctival veins and venules resulting in a whiter appearance of the eyes. Additionally, instances of rebound redness and tachyphylaxis–which products like Visine (0.05% tetrahydrozoline hydrochloride) and ClearEyes (0.012% naphazoline hydrochloride) are known for–are rare with brimonidine use. Therefore, Lumify can be a powerful tool in managing a patient’s cosmetic concerns as it relieves ocular injection within minutes, can be used up to four times per day and lasts for five-eight hours.

While punctal plugs are sometimes used in the management of dry eye, their use in the presence of ocular rosacea is controversial. The therapeutic goal of plugs is to increase the tear volume that remains on the ocular surface by reducing drainage through the puncta. But in the case of ocular rosacea, numerous inflammatory factors are elevated in the tear film, so occluding the puncta may create a “cesspool” effect, in which a stagnant pool of inflammatory factors remains on the ocular surface for a longer period provoking further inflammation.

The use of amniotic membranes can be helpful in more severe corneal cases of ocular rosacea, particularly in cases of persistent epithelial defects and ulceration. Amniotic membranes have robust anti-inflammatory and healing properties that can be a powerful tool in managing rosacea keratitis.

A particular area of concern for some ocular rosacea patients is contact lens wear. While ocular rosacea patients can wear contact lenses successfully, it is best to advise these patients to avoid lens wear during periods of acute inflammation or discontinue lens wear until their condition is well controlled, as contact lens wear itself may be intrinsically inflammatory.

Likewise, the health of the ocular surface should be optimized before fitting lenses in ocular rosacea patients. It is strongly recommended that ocular rosacea patients be fit in daily disposable lenses for increased comfort and ocular surface health. In some cases, it may be necessary for patients to discontinue contact lens wear indefinitely if lens use appears to be a significant irritant or elicits worsening of their condition, such as increased neovascularization.