Good Hope, Heartlands, and Solihull Eye Clinics

Rosacea keratitis (RK)

David Kinshuck

What is Rosacea keratitis (RK)

Rosacea is a skin condition causing red facial skin and her skin changes.  Rosacea keratitis occurs when the condition affects the surface of the eye itself, the cornea.

It consists of eyelid changes (a type of blepharitis) and corneal changes.

 

 

Blepharitis

All RK patients have blepharitis (Blepharitis is the medical term for inflamed eyelids). The inflammation is like eczema of the skin, with red, scaly eyelids. You may notice tired, or gritty eyes, which may be uncomfortable in sunlight or a smoky atmosphere. They may be slightly red, and feel as though there is something in them. The eyelids have tiny glands in them, especially the lower lids. These glands make substances that mix with tears, and help the tears to spread across the eye. There may be fungi in the lids Eye 15, or demodex mite.

 

meibomian glands, diagram, side view

side view

meibomian glands, diagram, front view

front view

 

 

 

 

 

 

 

 

The glands in the eyelids shown in purple

 

This thin layer of tears lubricates the eyes, stops them drying out, and keeps them comfortable.

 

healthy tear film, side view

side view

healthy tear film, front view

front view

 

 

 

 

 

 

 

 

Evenly spreading tears: a comfortable eye

 

 

poor tear film in blepharitis

side view

poor tear film in blepharitis

front view

 

 

 

 

 

 

 

 

Poorly spreading tears: dry patches develop on the surface of the eyes making them sore.

However, as you get older, and particularly if you have dry skin, these glands can block. As a result the glands do not make the chemicals that enables the tears to  spread evenly across the front of the eye. As a result, the tears break up, and dry patches develop develop on the surface of the eye. These patches make the eyes feel sore or gritty.

 

Rosacea keratitis/ ocular rosacea / Blepharokeratoconjunctivitis

In this condition additional changes occur.

Treatment

  1. The treatment is aimed at first treating the blepharitis:
  2. Unblocking the glands in the eyelid, which may be infected and inflamed, like acne on the face or a tiny boil by lid cleaning .  
    • Soak a tissue in hot water (not hot enough to burn), and press it against the upper and lower eyelids. This helps to unblock the glands. Bathe the eyelids for 5 minutes. The bottom lid is easier to bathe and usually the most important to clean. Blepharaclean wipes are now the most effective way of cleaning the eyelids. (Available with or without prescription from pharmacies.)
      There may be in infection of the eyelid with an invisible mite demodex. It is likely this is killed by ointments such as VitApos. Even with treatment your eyes may remain a little sore, but no harm will come to them and there is nothing to worry about.
    • https://healthyfocus.org/how-to-kill-demodex-mites/
  3. Lid bathing.
    • 5 minutes bathing the eyelids, upper and lower, with a tissue soaked in hot water (not hot enough to burn), gently wiping or massaging them. Repeat this at least twice a day for a few days, then twice a week. Ask your clinic nurse to show you this procedure.
      The more effective bathing method is with heated masks: Blephamask (see Altacor) or Meibopatch.  (Meibopatch available on prescription). Some people find these heated masks very helpful, use for 5 minutes twice daily.
  4. It may take two weeks for any improvement. It is safe to stop cleaning, but you may need to start again if the condition returns.
  5. Replacing the tears if the eyes are dry with Lubricants (dry eyes and blepharitis may occur together). There are many drops, such such as Hyloforte, Hylocare, Clinitas soothe, and others, but they must be preservative free.
  6. Smoking will make the condition much worse. (Too much alcohol will also be harmful.)
  7. If possible  reduce doses of drugs likely to contribute to sore eyes, although this is often not possible as they are often essential. Proton pump inhibitors often contribute and their dose can often be reduced.
  8. A healthy diet: BMJ 18 Changed a little: eat minimally processed food (fruit nuts, seeds, beans, vegetables, whole grains, plant oils, live yoghurt): avoid ultraprocessed foods rich in refined starch and sugars, and industrial additives such as trans-fats and salt.  Blepharitis is linked to a high cholesterol/lipids. BJO 18, so it is likely lowering cholesterol should be part of the treatment.. See. NHS Direct  oily fish may help, but omega 3 supplements don't help
  9. Treating any infection present with antibiotic cream. Rub antibiotic into margins for more severe cases (Polyfax, chloramphenicol, or Fucithalmic or azithromycin).
  10. More severe cases: treat infection and reduce the inflammation using antibiotic tablets .
    • Doxycycline 100mg once daily (keep out of sun if using: sunburns easily), stomach problems, drug interaction, not suitable for children/pregnancy.
    • erythromycin dose 250/400 4 times  a day (lower dose after 4 weeks?).
    • Azithromycin 500mg once daily for 3 days can help, a very short course.
  11. Steroid drops e.g. dexamethasone  without preservative
  12. or Maxidex ( dexamethasone with preservative)
    • (a typical patient)
    • 4 times a day for a week
    • 3 times a day for a week
    • 2 times a day for a week
    • once a day for a months
    • alternate days for some time
    • steroids contribute to cataract; more importantly they cause a pressure rise in 1/8 , so the pressure must be taken after 2 weeks and 2 months and if used long term
  13. Topical tacrolimus (Protopic 0.03% twice a day) in addition for severe corneal involvement (or steroid sparing). Average 2y treatment, 12% treatment failure

Rosacea in children: Blepharo-keratoconjunctivitis

Treatment for children (after Tuft 2015)