http://informahealthcare.com/cot ISSN: 1556-9527 (print), 1556-9535 (electronic) Cutan Ocul Toxicol, Early Online: 1–6 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/15569527.2014.930749 REVIEW ARTICLE Rosacea – the ophthalmic perspective Muhammad Awais 1 , Muhammad Irfan Anwar 1 , Raheel Iftikhar 1 , Zohaib Iqbal 1 , Nazia Shehzad 2 , and Bushra Akbar 3 1 United Nations & African Mission in Darfur, Nyala, Sudan, 2 Rasheed Hospital, Lahore Cantt, Pakistan, and 3 Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan Abstract Context: Rosacea is a chronic cutaneous inflammatory disorder with variable presentations. Although primarily considered a skin disease, rosacea may involve the eyes in a significant number of patients leading to ocular complications. It has been recognized that many patients of ocular rosacea in dermatological outpatient department (OPD) go unnoticed as the physicians don’t ask about eye symptoms. Same holds true in ophthalmic OPD’s where the doctors usually don’t consider this diagnosis. The diagnosis of ocular rosacea primarily relies on observation of ophthalmic clinical features but it can be easily missed if accompanying cutaneous features are subtle or inconsistent. The subject diagnosis if not diagnosed and treated promptly, may cause varying degrees of ocular morbidity and may impair vision secondary to corneal involvement. Objective: To review published literature and provide an overview on different pathophysiologic mechanisms of ocular rosacea and clinical features required for its diagnosis. As well as to highlight various treatment modalities available for ocular rosacea. Materials and methods: In our study Medline and Google Scholar were the key search engines to find literature using keywords like epidemiology, pathogenesis, clinical features, management and complications of ocular rosacea. Keywords Dry eyes, interleukin-1, ocular Rosacea History Received 28 April 2014 Revised 20 May 2014 Accepted 28 May 2014 Published online 8 July 2014 Introduction Rosacea is a chronic dermatologic condition of vasomotor instability that primarily affects blood vessels and pilosebac- eous units of the central facial skin (cheeks, chin, nose, and central forehead) causing transient or persistent erythema, telangiectasias, papules, pustules, phymatous changes and ocular involvement 1,2 . Generally fair-skinned young to middle-aged adults are more predisposed. Depending on its clinical manifestations, the disease is categorized in 4 sub- types: erythematotelangiectatic, papulopustular, phymatous, or ocular rosacea 2–4 . In addition to these 4 subtypes, another variant termed granulomatous rosacea is also recognized 3 . About 58–72 % of rosacea patients develop ocular manifest- ations, which range from minor irritation, dryness, and blurry vision to potentially severe ocular surface disruption and inflammatory keratitis, corneal ulceration and eventual per- foration 1,5 . Ocular signs may even precede characteristic skin involvement in 20% of the cases 6 . A major reason for under diagnosis of ocular rosacea is patients often do not mention ocular symptoms in a dermatology clinic. A collaborative effort between dermatology and ophthalmic consults is mandatory for early diagnosis and adequate treatment of ocular rosacea. Pathophysiology Although exact pathophysiologic mechanism of ocular ros- acea is still unclear it is generally considered to be comprised of inflammatory changes, altered immune system responses and vascular dysregulation 7–9 . The studies support- ing inflammatory nature of the disease demonstrate elevated concentration of interleukin-1a and b, gelatinase B (metallo- proteinase-9) and collagenase-2 (MMP-8) in the tear fluids of patients with ocular rosacea 10–13 . Elevated serum level of Tumor necrosis factor (TNF-alfa) and overexpression of ICAM-1 (intercellular adhesion molecule 1) and HLA-DR in conjunctival epithelial cells of these patients is also observed 14,15 . Patients of ocular rosacea demonstrate abnor- mally enhanced sensitivity to common environmental stimuli like sun exposure, extremes of weather, spicy foods, heated beverages, emotional stress, strenuous exercise, alcohol consumption, certain skin care products, medications such as amiodarone, topical steroids, nasal steroids, and high doses of vitamins B6 and B12 and dairy products 16,17 . These factors contribute in activation of inflammatory and immune systems and express an enhanced level of Toll-like receptor 2 (TLR2) in the epidermis 14 . TLR2 in keratinocytes leads to an increase in activity of an enzyme serine protease KLK5 which has a Address for correspondence: Muhammad Irfan Anwar, Consultant Dermatologist, United Nations & African Mission in Darfur, Nyala, Sudan. E-mail: doctorirfananwar@gmail.com Cutaneous and Ocular Toxicology Downloaded from informahealthcare.com by 41.223.163.111 on 07/11/14 For personal use only.