Ocular Symptoms Common in Rosacea, But Often Undiagnosed

Markus Reinholz, MD, PhD

Half of patients with rosacea have ocular involvement, but a significant number of cases go undiagnosed due to a lack of symptom specificity, according to a new analysis.

The report was a rare large-scale study of ocular rosacea that offered insights into how physicians could better identify and treat patients with rosacea who may have eye involvement.

Corresponding author Markus Reinholz, MD, PhD, of the University Hospital of Munich, and colleagues, noted that rosacea is most identifiable as an inflammatory disease affecting the facial skin, but it can also extend to the eyes.

However, the author said the ocular manifestations of the disease have received relatively little attention until recently. Yet it remains a multidisciplinary challenge.

“Ophthalmic rosacea can affect the eyelids (blepharitis, chalazion, and meibomianitis), the conjunctiva (conjunctivitis and keratoconjunctivitis sicca), the iris (iritis and iridocyclitis), and the cornea (corneal thinning, ulceration, and superficial keratitis),” they wrote.

Patients with the condition often report symptoms such as burning, tearing up, and photophobia. The condition is generally classified into one of 3 categories, based on severity.

Though much is known about the disease, at least 2 major questions remain: first, how exactly does the disease come about and second, how common are ocular manifestations among patients with rosacea.

In an effort to answer the latter question, the investigators developed a detailed online questionnaire, which was given to 777 patients with rosacea.

The survey asked patients questions about ocular and skin symptoms, type 1 hypersensitivities, Demodex testing results, and their previous experiences with healthcare professionals.

The surveys showed that a slight majority (399 of 777) experienced ocular symptoms. The most common were styes and chalazia (309 of 399), itching (187 of 399), and red eyes (179 of 399).

About half of the patients (393) in the study had type 1 hypersensitivity, and more than half of those (225) said they suffered from ocular symptoms.

The investigators said it is important for physicians to question patients with rosacea about ocular symptoms. If symptoms are present, it is beneficial to refer patients to an ophthalmologist for a full examination, since eye symptoms are often unspecific and may or may not be related to rosacea.

In the study cohort, 309 patients had previously consulted an opthalmologist, and about half (149) were confirmed to have ocular rosacea.

If patients do have ocular rosacea, Reinholz and colleagues said, dryness of eyes can be helped by intense pulsed light (IPL) therapy and the use of artificial tears with omega-3 fatty acids, according to previous studies.

The investigators also discussed the topic of Demodex infection, since it has been discussed as a probable trigger of ocular rosacea. In the current study, no statistically significant association was identified between Demodex prevalence and ocular rosacea manifestation.

That may be because Demodex-induced symptoms could be dose-dependent or dependent on individual immunologic mechanisms, they said. In the study, 45 patients were Demodex-positive, and just half (21) had ocular symptoms.

The authors said their study’s strength is its large size and broad scope of symptoms, but they said more work will be needed to better understand the mechanisms that cause ocular rosacea to develop, as well as the role of potential risk factors.

“Here, immunological studies will be key to elucidate the exact triggers of this chronic inflammatory disease,” they said.

The study, "Clinical clues to identify patients with ocular rosacea – a Germany-wide epidemiologic analysis," was published online in the International Journal of Dermatology.