Good Hope, Heartlands, and Solihull Eye Clinics

Blepharo-keratoconjunctivitis (Rosacea keratitis  RK)

David Kinshuck

What is Blepharo-keratoconjunctivitis / 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.

 

Blepharokeratoconjunctivitis / Rosacea keratitis/ ocular rosacea

In this condition additional changes occur.

Treatment

  1. The treatment is aimed at first treating the blepharitis: Blepharitis treatment NHS. healthyfocus.org/how-to-kill-demodex-mites/

Very brief

  1. Heat compresses and massage twice a day
  2. Blephaclean or blephasol twice a day
  3. Preservative free lubricant
  4. vitaPos night

More details

  1. Lubricants
    • 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.
    • VitApos at night
  2. Smoking will make the condition much worse. (Too much alcohol will also be harmful.)
  3. 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.
  4. A healthy diet: BMJ 18 Minimally processed food is prefered (vegetables, 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
  5. Treating any infection present with antibiotic cream. Rub antibiotic into margins for more severe cases (Bactroban 2% (Mupirocin)  Polyfax, chloramphenicol, or Fucithalmic or azithromycin).
  6. 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.
  7. Steroid drops e.g. dexamethasone without preservative 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 month
    • 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
  8. Topical tacrolimus (Protopic 0.03% twice a day) in addition for severe corneal involvement (or steroid sparing). Average 2y treatment, 12% treatment failure

Blepharokeratoconjunctivitis in children

separate page

blepharitis

mixed (mainly anterior) blepharitis

This is a type of chronic conjunctivitis in children. Essentially conjunctivitis develops but does not get better with treatment, and there is also a blepharitis. 'Kertitis' is the medical name for disease of the cornea.

Treatment for children (TK for Good Hope 2020)

  1. Often one eye
  2. Clean with wipes, various available for purchase from chemist
  3. Hot bathing with Eyebag or equivalent (material heated to a specific temperature in the microwave)
  4. Lids must be clean..this is very important. It is important to change lid 'flora'.
  5. Azithromycin systemically
    1. twice a day for 3 days of week one,
    2. repeat first week of each month for 3 months
  6. Occasionally azithromycin for lids twice a day for 3 days if there is an infection
  7. Dexamethasone (steroid eye drop) preservative free 4 times a day 3 days then reduce
  8. Corneal scarring will generally need long term
    1. Verkazia 4 times a day (this stings for the first few days) or
    2. Protopic (tacrolimus 0.03%) on lids some must go in eye
  9. Preservative free lubricant
  10. Epithelium punctate staining is related to disease activity not dryness, will need some lubricants
  11. If the cornea not scarred should be able to control most of disease with cleaning and heat after initial treatment, without long term steroids/Cyclosporine/Protopic
  12. Average 2y treatment, 12% treatment failure
  13. cornea
    • superficial keratitis
    • leukomas
    • corneal vascularisation
  14. there will be occasional flare ups when a short course of steroid drops will be needed