Ocular Signs of Rosacea
Ocular rosacea presents with bilateral chronic blepharitis, eyelid margin telangiectasias, meibomian gland dysfunction with inspissation and excessive sebum secretion, conjunctival injection, evaporative dry eye, chalazia, and characteristically shows inferior involvement of the ocular surface. 1
Primary Ocular Signs
Eyelid Manifestations
- Eyelid margin telangiectasias are a hallmark finding and help distinguish rosacea from other causes of blepharitis 1
- Chronic bilateral blepharitis with irregularity of the lid margins is present in nearly all cases 1, 2, 3
- Meibomian gland dysfunction (MGD) occurs in 100% of patients, characterized by inspissation with excessive sebum secretion and gland orifice narrowing or pouting 1, 2
- Recurrent chalazia are common, particularly in children where they may be the presenting sign before facial manifestations appear 1, 4
Conjunctival Findings
- Conjunctival injection and hyperemia with chronic blepharoconjunctivitis 1, 5
- Inferior conjunctival involvement is characteristic and helps differentiate from other forms of conjunctivitis 1
Corneal Complications
- Punctate epithelial keratopathy occurs in approximately 67% of cases 2
- Corneal neovascularization develops in 50% of patients, often with inferior pannus formation 1, 2, 3
- Stromal scarring from chronic inflammation 1
- Corneal ulceration and perforation represent severe complications that can lead to vision loss 1, 3
Tear Film Abnormalities
- Evaporative dry eye from MGD is a consistent finding 1
- Reduced tear film break-up time and Schirmer test values 2
Clinical Context and Epidemiology
Ocular involvement is present in approximately 75% of patients with cutaneous rosacea, though ocular signs may precede or occur without facial manifestations 1, 5. The condition follows a chronic inflammatory course with episodic flares 1.
Population Characteristics
- More frequently observed in fair-skinned individuals, though it occurs in all races and both sexes 1
- Women are affected more often, but men tend to have more severe disease 1
- In children, ocular manifestations often precede facial findings, with facial rosacea being less frequent and associated atopy being common 1, 4
Serious Complications and Red Flags
Vision-Threatening Sequelae
The potential for severe complications including corneal neovascularization, stromal scarring, ulceration, and perforation makes prompt recognition critical 1. In one series, 13 patients presented with decreased visual acuity from corneal complications, 6 required penetrating keratoplasty, and 1 underwent enucleation for corneal perforation and endophthalmitis 3.
Pediatric Considerations
Children with ocular rosacea often present with corneal involvement, asymmetry of ocular disease, and greater potential for visual impairment including corneal melting and perforation compared to adults 1, 4. The diagnosis is frequently overlooked because facial signs are subtle, and children may present only with chronic recurrent keratoconjunctivitis, phlyctenules, punctate erosions, or recurrent chalazia 1, 4.
Children with a history of recurrent styes have an increased risk of developing adult rosacea, making this presentation clinically significant rather than benign 1, 4.
Associated Cutaneous Findings
When present, facial manifestations include the characteristic malar rash, facial erythema, telangiectasias, papules, pustules, prominent sebaceous glands, and rhinophyma 1. However, rosacea may be difficult to diagnose in patients with darker skin tones because telangiectasia and facial flushing are not easily visualized 1.
Common Diagnostic Pitfalls
- Overlooking the diagnosis in children who present with recurrent chalazia or styes without obvious facial manifestations 1, 4
- Missing ocular rosacea in patients with darker skin where facial telangiectasia is not visible 1
- Failing to recognize asymmetry of ocular involvement in children, which strongly suggests ocular rosacea 4
- Dismissing recurrent unilateral blepharitis that is unresponsive to therapy, which may indicate sebaceous carcinoma rather than rosacea 4, 6
Role of Demodex
Demodex folliculorum load is increased in individuals with rosacea and may play a role in pathogenesis 1. Eyelashes with cylindrical dandruff or sleeves at the base are reported as a sign of ocular Demodex infestation, with severity of symptoms correlating positively with the number of Demodex per cilium 1.