What is the recommended management for ocular rosacea and should patients follow up with an ophthalmologist?

Management of Ocular Rosacea

For ocular rosacea, patients should follow a stepwise treatment approach starting with eyelid hygiene and artificial tears, progressing to oral doxycycline for non-responsive cases, and should be referred to an ophthalmologist for moderate to severe cases that cannot be controlled with basic measures. 1, 2

First-Line Treatment

• Begin with daily eyelid hygiene to reduce inflammation and bacterial load 2
• Add artificial tear substitutes for mild ocular burning/stinging symptoms 2
• Implement general skincare and trigger avoidance (including sun protection with SPF 30+, moisturizers, gentle cleansers) 1
• Allow sufficient time (6-12 weeks) to evaluate effectiveness before considering treatment failure 1

Second-Line Treatment

• Oral doxycycline is the first-line pharmacological treatment for cases not responding to basic measures 2
  • Available in standard formulations (≥50 mg with antibiotic activity) 1
  • Also available as 40-mg modified-release dose with anti-inflammatory but not antibiotic activity in some regions 1
  • The 40-mg formulation has fewer side effects than higher doses while maintaining efficacy 1
• Oral azithromycin can be used as an alternative to tetracyclines 1
  • Dosing regimen: 500 mg per day for 3 days in three cycles with 7-day intervals, or 1 g per week for 3 weeks 1
  • Note: FDA has issued warnings about potential cardiac risks with azithromycin 1

Additional Treatments

• Topical cyclosporine 0.05% may be helpful for posterior blepharitis 1, 2
• Brief course of topical corticosteroids for severe eyelid or ocular surface inflammation 1, 2
  • Should be tapered once inflammation is controlled 1
  • Long-term corticosteroid therapy should be avoided due to risks of increased intraocular pressure and cataract 1
  • Consider site-specific corticosteroids like loteprednol etabonate or fluorometholone phosphate to minimize adverse effects 1

When to Refer to Ophthalmology

• Referral to an ophthalmologist is necessary for: 1, 2
  • Ocular rosacea that cannot be controlled with lid hygiene 1
  • Moderate to severe cases with symptoms like blurred vision, foreign body sensation, interpalpebral bulbar hyperaemia, photophobia, significant redness, or telangiectasia 1, 2
  • Cases with corneal involvement 2
  • Cases requiring specialized treatments beyond basic measures 2

Special Considerations

• Tetracyclines should not be used in children under 8 years of age (risk of teeth staining); oral erythromycin or azithromycin may be substituted 1
• Tetracyclines can sensitize skin to sun exposure 1
• Combination therapy may be required for moderate to severe presentations 1
• Maintenance therapy should use the minimum treatment necessary to maintain control 1
• The most effective treatment modalities based on recent research include topical antimicrobials, oral antibiotics, intense pulsed light, and cyclosporine ophthalmic emulsion 3

Treatment Efficacy

• Topical antimicrobials and oral antibiotics achieve complete or partial response in 91% and 89% of patients respectively 3
• Cyclosporine ophthalmic emulsion shows effectiveness in 87% of patients 3
• Lid hygiene alone is effective in 65% of patients 3
• Combination treatments achieve complete or partial response in 90% of patients 3

Pitfalls to Avoid

• Delaying referral to ophthalmology for cases with corneal involvement or significant symptoms 2
• Prolonged use of corticosteroids around the eyes 1
• Insufficient treatment duration before determining treatment failure 1
• Overlooking ocular rosacea in the absence of cutaneous features, particularly in children 4