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Rosacea (an inflammatory skin disease that causes flushing and redness of the face) does not always stay in the skin. In many people with rosacea it also affects the eyelids and eyes, and shows up as burning, dryness and red eyelids. This page is for you if you already know you have rosacea on your face, or if your eyes have been red and burning for a long time and no drop really helps.
What ocular rosacea is
Ocular rosacea is the expression of the same inflammatory tendency around the eyes. It mainly affects the eyelid margins and the meibomian glands (small glands in the eyelid margins that secrete the oily layer of the tears). When these glands do not work properly, the tears evaporate too quickly, and the result is an "evaporative" type of dry eye.
The confusing thing is that the severity in the skin and in the eyes does not always match. Some people have marked redness of the face and almost quiet eyes, and some people's eyes suffer even before anyone has noticed the skin. That is why ocular rosacea often remains undiagnosed for years.
Why rosacea causes eye symptoms
In rosacea the small blood vessels in the skin dilate easily, and there is a tendency to ongoing inflammation. Around the eyelids this shows up as small dilated blood vessels at the eyelid margin, inflammation around the openings of the meibomian glands and a thick secretion that blocks them. The oil that comes out of the glands changes, and the tear film breaks up quickly.
In some people with rosacea, more Demodex mites (a tiny creature that lives in the lash follicles) have also been found at the eyelid margins. The result is a circle: inflammation damages the glands, blocked glands increase dryness, and dryness increases inflammation.
How ocular rosacea is recognised
The symptoms are similar to dry eye from other causes, but there are a few signs worth paying attention to:
- Burning, a gritty or foreign-body feeling, and eyes that tire quickly.
- Red, thickened eyelid margins, sometimes with small visible blood vessels.
- Styes and chalazia (lumps in the eyelid) that keep coming back. More on this on the stye and chalazion page.
- Redness of the eye that gets worse after alcohol, hot drinks, spicy food, heat or sun, just like the flushing of the face.
- Sensitivity to light and watering (watery eyes), which sometimes, surprisingly, comes from dryness.
If you also have mild flushing of the cheeks, nose or forehead, or have already been diagnosed with rosacea, tell the eye doctor. This information changes the picture and the choice of treatment.
What the eye doctor checks
The diagnosis is made by clinical examination, without a special blood test. In the slit-lamp examination (a microscope with which the eye doctor examines the eye), the doctor looks at the eyelid margins, the openings of the glands and the quality of the secretion when the glands are gently pressed. The doctor checks how quickly the tear film breaks up with the help of fluorescein dye (a harmless yellow-orange dye), and whether there is damage to the surface of the cornea.
The examination also includes a search for Demodex at the base of the lashes and for signs of damage to the cornea, which is the most important part for preserving vision. In most cases ocular rosacea is mild to moderate, but in a few cases it can cause inflammation of the cornea, and then fast treatment and close follow-up are needed. Details of the tests at the clinic are on the dry eye testing page.
Treatment options
The foundation: daily eyelid care
Treatment almost always starts at home: warming the eyelids to soften the secretion in the glands, gentle cleaning of the eyelid margins and preservative-free lubricating drops. An explanation of how to warm the eyelids properly is on the warm compresses for the eyes page. It is also worth identifying the factors that trigger a flare-up for you, such as sun, heat or alcohol, and reducing them as much as possible.
Medical treatment
When the foundation is not enough, the eye doctor may prescribe anti-inflammatory drops, ointments for the eyelids, or a low-dose treatment by mouth from the tetracycline group, intended mainly to reduce inflammation and improve the quality of the oil in the glands. Every medicine has benefits and side effects, and the doctor will adapt it to your condition and to the other medicines you take.
Treatments at the clinic
When the glands are blocked and the inflammation persists, there are treatments done at the clinic that may help:
- IPL treatment: broad-spectrum pulsed light directed at the skin below the eyes. It has been used for years to treat the redness of rosacea on the skin, and in some patients it also improves the function of the meibomian glands. It is important to know that IPL is not a laser, but filtered broad-spectrum light.
- Meibomian gland expression: gentle emptying of the blocked glands after warming, often combined with IPL.
- BlephEx treatment: thorough cleaning of the eyelid margins that removes a layer of debris and bacteria, and is particularly suitable when there is also blepharitis or Demodex.
Not every treatment suits everyone. For example, suitability for IPL depends on skin tone and on the medicines you take. The plan is built after an examination, and usually combines treatment at the clinic with continued regular care at home.
What to expect from treatment
Ocular rosacea is a chronic condition, so the aim is control, not a one-off cure. Improvement usually comes gradually, over several weeks, and not immediately after one treatment. In many people the symptoms decrease greatly, but they come back if eyelid care is stopped completely.
So it is worth treating home care as a regular habit, like brushing your teeth, and not as something you do only when it hurts. At follow-up visits the condition of the glands and cornea is checked, and it is decided whether treatment can be reduced or something needs to be added. During flare-ups, for example in summer or after long exposure to the sun, you may need more intensive treatment for a while.
Daily steps that can help
- Keep a regular routine of warming and cleaning the eyelids, even in quiet periods.
- Protect your eyes and skin from the sun with sunglasses and a wide-brimmed hat.
- Notice which foods, drinks or situations trigger flushing for you, and try to reduce them.
- Avoid heavy make-up on the eyelid margins, and remove make-up gently every evening.
- If you work at a screen, remember to blink and take short breaks.
Working together with the dermatologist
Rosacea is one disease with two "areas". The dermatologist treats the redness, spots and blood vessels on the face, and the eye doctor treats the eyelids, the glands and the cornea. Some treatments affect both areas, so it is worth each doctor knowing what the other has prescribed. Bring an up-to-date list of the medicines, creams and drops you use to every visit.
When to see a doctor straight away: severe eye pain, reduced vision, marked sensitivity to light, a white or grey spot on the cornea, or a very red eye that is getting worse quickly. These may be signs of inflammation of the cornea, and you should be examined by an eye doctor or at an eye emergency department the same day.
In summary
If you have rosacea on your face and eyes that burn and turn red, it may be ocular rosacea. This is a common condition that is often not diagnosed. Regular eyelid care is the foundation, and when that is not enough, an examination by a dry eye specialist can reveal the condition of the glands and tailor treatment aimed at the root of the problem.
Want a basic explanation first?For basic information on the meibomian glands: the guide on the Mitzmutz site
Frequently asked questions
Can you have rosacea in the eyes without signs on the skin?
Yes. In some people the eye signs appear before the skin signs, or when the skin looks almost normal. That is why the eye doctor also asks about flushing and redness of the face.
Does ocular rosacea go away?
Rosacea is a chronic condition that tends to flare up and settle down. With the right treatment and regular eyelid care, it is usually possible to reduce the symptoms and the number of flare-ups.
Is IPL treatment suitable for ocular rosacea?
IPL (broad-spectrum pulsed light, not a laser) has long been used to treat the redness of rosacea on the skin, and in some patients it may also improve the function of the meibomian glands. Suitability is decided at an examination. More about IPL treatment.
Who treats rosacea, a dermatologist or an eye doctor?
Often both. The dermatologist treats the facial skin, and the eye doctor treats the eyelids, the glands and the cornea. Coordination between the two helps in choosing treatment that suits both areas.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Vieira AC, Mannis MJ. Ocular rosacea: common and commonly missed. J Am Acad Dermatol. 2013;69(6 Suppl 1):S36-S41.
- Amescua G, Akpek EK, Farid M, et al. Blepharitis Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P56-P93.
- Geerling G, Tauber J, Baudouin C, et al. The International Workshop on Meibomian Gland Dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):2050-2064.
- Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46.
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.