Rosacea, a prevalent skin condition, manifests as mid-facial flushing, redness, pronounced vasculature, swelling, papules, and/or pustules. A specific type of rosacea, known as ocular rosacea, affects the eyelids and the front part of the eye, encompassing conditions like blepharitis, conjunctival hyperaemia, and rosacea-associated keratitis. Ocular rosacea is observed in both adult men and women, often emerging around the age of 56, though it is rare in children and typically begins post-30 years. It frequently presents in individuals already diagnosed with rosacea, occasionally marking the first indication of the disease.

The underlying causes of ocular rosacea remain uncertain, with immunological factors, skin surface micro-organisms, and reactive blood vessels implicated in its development. Demodex mites residing in eyelash follicles may incite inflammation, while bacterial activity is suggested to exacerbate the condition, possibly through the release of toxic substances from meibomian gland secretions. Additionally, the pro-inflammatory cytokine interleukin 1-alpha is known to elevate levels of metallomatrix protein-9 in tear fluid, contributing to ocular tissue damage.

Symptoms of ocular rosacea predominantly affect the eyelids, conjunctiva, and cornea, and less frequently, the iris and sclera. Individuals may experience itching, burning, increased tear production, light sensitivity, a sensation of a foreign object in the eye, dry eye, inflamed papules, corneal ulcers, and redness. Clinically, anterior blepharitis impacts the lid margin and lash line, leading to swelling, redness, scale formation at the eyelash base, and eyelash loss or misdirection. Posterior blepharitis, on the other hand, results from meibomian gland dysfunction, manifesting as conjunctival hyperaemia, cloudy secretions, and conjunctival scarring, among other signs. Corneal inflammation, though rare, poses a significant threat to vision, characterized by superficial erosions, increased blood vessels, and, in severe cases, corneal thinning and perforation.

Diagnosis of ocular rosacea can be challenging, particularly in the absence of cutaneous rosacea, and may involve differentiating from conditions such as seborrhoeic dermatitis and periorificial dermatitis. 

Various approaches are available for managing ocular rosacea, ranging from basic care to more advanced treatments. For basic care, maintaining eyelid cleanliness is crucial, utilizing diluted baby shampoo, bicarbonate solution, or specialized formulas applied with a cotton swab to cleanse the eyelid edges and eliminate scales. Applying warm compresses to the eyes for five to ten minutes each day can enhance the secretion flow from the meibomian glands, and help manage chalazion and styes. The use of artificial tears can alleviate symptoms associated with dry eyes, and it’s advisable to avoid contact lenses if they exacerbate eye irritation.

For direct antimicrobial treatment, anterior blepharitis can be effectively managed with a variety of topical antiseptics and antibiotics, including erythromycin, metronidazole, azithromycin, bacitracin, polymyxin B, and fusidic acid. Inflammation can be reduced with topical nonsteroidal anti-inflammatory drugs such as ibuprofen. Topical steroids may be temporarily employed to address significant eyelid inflammation or keratitis caused by rosacea, but their prolonged use is discouraged due to the risk of inducing glaucoma and cataracts. For cases resistant to topical steroids, topical ciclosporin is often prescribed.

Systemic antibiotics, including tetracyclines like doxycycline and macrolides such as erythromycin, are utilized to diminish bacterial presence, stabilize the tear film, and regulate meibomian gland secretions. These oral antibiotics are typically prescribed for a period of 6–12 weeks, followed by a gradual reduction over one to two months, with additional courses possible for flare-ups. Styes not resolving with topical treatments may necessitate oral anti-staphylococcal antibiotics like flucloxacillin.

Oral isotretinoin, administered in low doses, can treat ocular rosacea but must be used with caution due to potential adverse effects including infection risks, dry eyes, and other eye-related issues. Some patients with dry eye conditions have found oral omega-3 fatty acid supplements to be beneficial.

Surgical options may be needed to correct corneal damage such as opacification or perforation resulting from rosacea keratitis, through a procedure known as keratoplasty. Additionally, hordeola that do not respond to conservative treatments might require surgical removal.