Bilateral chronic ocular irritation, dry eyes, redness, burning, photophobia, and foreign body sensation. Typically middle-aged adults, but it can be found in children. More common in women. Associated facial symptoms include recurrent facial flushing episodes, persistent midfacial erythema, telangiectasias, and papular skin lesions. 

Critical

Telangiectasias, pustules, papules, or erythema of the cheeks, forehead, and nose. Findings may be subtle especially in heavily pigmented individuals, often best seen under natural light. Superficial or deep corneal vascularization, particularly in the inferior cornea, is sometimes seen and may extend into a stromal infiltrate.

Other

Blepharitis, meibomian gland dysfunction, tear film insufficiency, and a history of recurrent chalazia are common. Conjunctival injection, SPK, phlyctenules, perilimbal infiltrates of staphylococcal hypersensitivity, iritis, or even corneal ulceration and perforation (rare) may occur. Rhinophyma of the nose occurs in the late stages of the disease, especially in men.

• Herpes simplex keratitis: Usually unilateral. Stromal keratitis with neovascularization may appear similar. See 4.16, Herpes Simplex Virus.

• See 4.1, Superficial Punctate Keratopathy, for additional differential diagnoses.

• See 4.23, Peripheral Corneal Thinning/Ulceration for peripheral ulcerative keratitis associated with systemic disease.

Unknown, however, thought to be an inflammatory condition with immune and vascular dysfunction. Signs and symptoms are often induced by certain environmental/local factors, including hot beverages (e.g., coffee or tea), tobacco, vasodilating medications, alcohol, and emotional stress.

1. External examination: Look at the face for the characteristic skin findings.

2. Slit-lamp examination: Look for telangiectasias and meibomitis on the eyelids, conjunctival injection, and corneal scarring and vascularization.

1. Warm compresses and eyelid hygiene for blepharitis or meibomitis (see 5.8, Blepharitis/Meibomitis). Treat dry eyes if present (see 4.3, Dry Eye Syndrome).

2. Avoidance of exacerbating foods, beverages, and environmental factors.

3. Doxycycline 100 mg p.o. b.i.d. for 1 to 2 weeks and then daily; taper the dose slowly once relief from symptoms is obtained. Some patients are maintained on low-dose doxycycline (e.g., 20 to 100 mg p.o. daily or less than daily) indefinitely if the active disease recurs when the patient is off medication. Erythromycin 250 mg b.i.d. to q.i.d. or oral azithromycin 500 mg/d × 3 days for three cycles with 7-day intervals, or 500 mg/d for 1 day followed by 250 mg/d for 4 days, are alternatives if doxycycline is contraindicated.

4. Consider oral omega-3 fatty acid supplements, cyclosporine 0.05% to 0.1%, or lifitegrast 5% drops b.i.d., and topical steroids for chronic rosacea-related ocular and eyelid inflammation (see 5.8, Blepharitis/Meibomitis).

5. Facial lesions can be treated with metronidazole gel (0.75%) application b.i.d. or azelaic acid gel (15%) application b.i.d.

6. Treat chalazia as needed (see 6.7, Chalazion/Hordeolum).

7. Corneal perforations may be treated with cyanoacrylate tissue adhesive if small (<1 to 2 mm), whereas larger perforations may require surgical correction. Doxycycline is indicated if there is a concern for corneal melting due to its anticollagenase properties.

8. If infiltrates stain with fluorescein, an infectious corneal ulcer may be present. Smears, cultures, and antibiotic treatment may be necessary. See 4.12, Bacterial Keratitis and Appendix 8, Corneal Culture Procedure.

NOTE Tetracycline derivatives such as doxycycline should not be given to pregnant women, nursing women, or children ≤8 years. Patients should be warned of increased sunburn susceptibility with the use of this medication.

NOTE Asymptomatic ocular rosacea without progressively worsening eye disease does not require oral antibiotics.

Variable; depends on the severity of the disease. Patients without corneal involvement are seen weeks to months later. Those with corneal involvement are examined more often. Patients with moderate-to-severe facial disease should also seek dermatologic consultation.