Ocular Rosacea:
Primary and Secondary Causes of Ocular Rosacea

Topics Discussed Below

• Flushing is the primary cause of rosacea
  
• Flushing can adversely affect the eye surface
  
• Flushing can adversely affect the eyelids
  
• Secondary causes of ocular rosacea
  
• Abnormality in meibomian gland activity
  
• Abnormality in the quantity and quality of tears
  
• Abnormality in goblet cell number and function
  
• References
  

I. Flushing is the Primary cause of Ocular Rosacea

Eye specialists indicate that ocular rosacea is primarily caused by frequent flushing and vascular dysfunction. (1-15)

1. Flushing can adversely affect the Eye Surface

• Frequent flushing disturbs the tear film of the eye surface.
  
  
• Frequent flushing causes inflammation on the eye surface due to penetration of inflammatory cells and cytokines through blood vessels. (16, 17)
  
  
• Frequent flushing activates sensory nerves on the eye surface and triggers burning sensations.

2. Flushing can adversely affect the Eyelids

• Frequent flushing causes substantial damage to the blood vessels of the eyelids.
  
• Frequent flushing causes swelling of the eyelids.
• Frequent flushing alters the production of oil from meibomian glands. (19)

II. Secondary Causes of Ocular Rosacea

Eye specialists also stress that abnormalities in meibomian gland activity, tear secretion and goblet cell activity can worsen ocular rosacea.

1. Abnormality in Meibomian Gland Activity

Many ocular rosacea sufferers experience meibomian gland dysfunction. (1, 5)    Rosacea sufferers may experience meibomian gland hyperactivity or hypoactivity:

• Hypersecretion of oil. Under these conditions, excessive amounts of oil are produced from the meibomian glands. Excess oil secretion can cause inflammation on the eye surface and within the eyelid. (5, 20-23)
  
  
• Hyposecretion of oil. Under these conditions, too little oil is produced from meibomian glands. This usually results from inflammation or blockage of the meibomian gland pores. (5, 20-23)  A thin, unstable layer of oil allows the water layer beneath to evaporate very quickly. (24)  Without a normal oil layer, the tear film can lose water up to 20 times faster!

One of the tell-tale signs of meibomian gland dysfunction is that eye irritation and burning usually get better as the day progresses. An ophthalmologist is able to diagnose meibomian gland dysfunction by examining the eyelids and meibomian gland secretions.

2. Abnormality in the Quantity and Quality of Aqueous Tears

Many studies indicate that rosacea sufferers may not produce enough tears, or that tear composition may be abnormal:

• In a study of 131 ocular rosacea sufferers, many were found to have decreased tear production. (1)
  
  
• In a study of 60 patients with ocular rosacea, Dr. Lemp and colleagues found that almost 40% of the patients did not produce adequate amounts of aqueous tear. (25)
  
  
• In a controlled study of 14 ocular rosacea sufferers, abnormalities in aqueous tear production/turnover were demonstrated in most sufferers. (18)
  
  

Some people do not produce enough tears to keep the eye surface comfortable. Others do not produce a good quality tear. Either of these abnormalities may lead to dry eye syndrome. One of the tell-tale signs of dry eye syndrome is that the sufferer usually experiences gritty irritation or burning of the eyes that gets worse as the day progresses. An ophthalmologist can diagnose dry eye syndrome by examining the eyes. In some cases, ophthalmologists may need to perform tests that measure tear production. One test, called the Schirmer tear test, involves placing filter paper strips under the lower eyelids to measure the rate of tear production under various conditions. Another test uses a diagnostic drop (fluorescein or Rose Bengal) to look for certain staining patterns.

3. Abnormality in Goblet Cell Number and Function

The surface of the eye normally contains thousands of mucous-producing goblet cells. Studies indicate that a substantial number of rosacea sufferers may have decreased goblet cells or impaired goblet cell activity. (17, 26) Mucous is central to stabilizing the tear film layer, so any abnormality in goblet cell number or function could cause eye symptoms in rosacea sufferers.

III.  References

1. Akpek, E.K., A. Merchant, V. Pinar, and C.S. Foster. Ocular rosacea: patient characteristics and follow-up. Ophthalmology 104: 1863-1867, 1997.
   
   
2. Browning, D.J. and A.D. Proia. Ocular rosacea. Surv Ophthalmol 31: 145-158, 1986.
   
   
3. Dahl, M.V. "Rosacea: red faces and adult acne, and red faces". Skin Care Today 5: 1999.
   
   
4. Chen, D.M. and D.L. Crosby. Periorbital edema as an initial presentation of rosacea. J Am Acad Dermatol 37: 346-348, 1997.
   
   
5. Driver, P.J. and M.A. Lemp. Meibomian gland dysfunction. Surv Ophthalmol 40: 343-367, 1996.
   
   
6. Barton, K., A. Nava, D.C. Monroy, and S.C. Pflugfelder. Cytokines and tear function in ocular surface disease. Adv Exp Med Biol 438: 461-469, 1998.
   
   
7. Wilkin, J.K. Rosacea. Pathophysiology and treatment. Arch Dermatol 130: 359-362, 1994.
   
   
8. Donshik, P.C., D.M. Hoss, and W.H. Ehlers. Inflammatory and papulosquamous disorders of the skin and eye. Dermatol Clin 10: 533-547, 1992.
   
   
9. Starr, P.A.J. and A. McDonald. "Oculocutaneous aspects of rosacea". Proc Roy Soc Med 62: 9-11, 1969.
   
   
10. Macsai, M.S., M.J. Mannis, and A.C. Huntley. "Acne Rosacea". In: Eye and Skin Disease, edited by M.S. Macsai, M.J. Mannis, and A.C. Huntley. Philadelphia: Lippincott-Raven, 1996, p. 335-341.
    
    
11. Jenkins, M.S., S.I. Brown, S.L. Lempert, and R.J. Weinberg. Ocular rosacea. Am J Ophthalmol 88: 618-622, 1979.
    
    
12. Frucht-Pery, J., E. Sagi, I. Hemo, and P. Ever-Hadani. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol 116: 88-92, 1993.
    
    
13. Culbertson, W.W., A.J. Huang, S.H. Mandelbaum, S.C. Pflugfelder, G.T. Boozalis, and D. Miller. Effective treatment of phlyctenular keratoconjunctivitis with oral tetracycline. Ophthalmology 100: 1358-1366, 1993.
    
    
14. Quarterman, M.J., D.W. Johnson, D.C. Abele, J.L.J. Lesher, D.S. Hull, and L.S. Davis. Ocular rosacea. Signs, symptoms, and tear studies before and after treatment with doxycycline. Arch Dermatol 133: 49-54, 1997.
    
    
15. Hoang-Xuan, T., A. Rodriguez, M.M. Zaltas, B.A. Rice, and C.S. Foster. Ocular rosacea. A histologic and immunopathologic study. Ophthalmology 97: 1468-1475, 1990.
    
    
16. Fukagawa, K. and et al. "Chemokine production in conjunctival epithelial cells". In: Lacrimal Gland, Tear Film, and Dry Eye Syndromes 2, edited by Sullivan and et al. New York: Plenum Press, 1999, p. 471-478.
    
    
17. Pisella, P., F.Brignole, C. Debbasch, PA Lozato, C.Cruezot-Garcher, J.Bara, P.Saiag, JM Warnet, and C Baudouin. Flow cytometric analysis of conjunctival epithelium in ocular rosacea and keratoconjunctivitis sicca. Ophthalmology 107(10): 1841-1849, 2000.
    
    
18. Barton, K., D.C. Monroy, A. Nava, and S.C. Pflugfelder. Inflammatory cytokines in the tears of patients with ocular rosacea. Ophthalmology 104: 1868-1874, 1997.
    
    
19. Stern, M.E., R.W. Beuerman, R.I. Fox, J. Gao, A.K. Mircheff, and S.C. Pflugfelder. A unified theory of the role of the ocular surface in dry eye. Adv Exp Med Biol 438: 643-651, 1998.
    
    
20. Bron, A.J., L. Benjamin, and G.R. Snibson. Meibomian gland disease. Classification and grading of lid changes. Eye 5 ( Pt 4): 395-411, 1991.
    
    
21. McCulley, J.P. and W.E. Shine. Meibomian secretions in chronic blepharitis. Adv Exp Med Biol 438: 319-326, 1998.
    
    
22. Bron, A.J. and J.M. Tiffany. The meibomian glands and tear film lipids. Structure, function, and control. Adv Exp Med Biol 438: 281-295, 1998.
    
    
23. McCulley, J.P., J.M. Dougherty, and D.G. Deneau. Classification of chronic blepharitis. Ophthalmology 89: 1173-1180, 1982.
    
    
24. Tsubota, K. Tear dynamics and dry eye. Prog Retin Eye Res 17: 565-596, 1998.
    
    
25. Lemp, M.A., M.A. Mahmood, and H.H. Weiler. Association of rosacea and keratoconjunctivitis sicca. Arch Ophthalmol 102: 556-557, 1984.
    
    
26. Pflugfelder, S.C., S.C. Tseng, K. Yoshino, D. Monroy, C. Felix, and B.L. Reis. Correlation of goblet cell density and mucosal epithelial membrane mucin expression with rose bengal staining in patients with ocular irritation. Ophthalmology 104: 223-235, 1997.
    
    
27. Kligman, A.M. Ocular rosacea. Current concepts and therapy. Arch Dermatol 133: 89-90, 1997.
    
    
28. Bonini, S. Mechanisms in adverse reactions to food. The eye. Allergy 50: 68-73, 1995.
    
    
29. De Groot, A.C. Fatal attractiveness: the shady side of cosmetics. Clin Dermatol 16: 167-179, 1998.
    
    
30. De Groot, A.C., J.W. Weyland, and J.P. Nater. "Percutaneous absorption of topically applied drugs". In: Unwanted Effects of Cosmetics and Drugs Used in Dermatology, edited by A.C. De Groot, J.W. Weyland, and J.P. Nater. New York: Elsevier, 1994, p. 226-523.

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