From: Subject: eMedicine - Ocular Rosacea : Article by J Bradley Randleman, MD Date: Sat, 3 Aug 2002 17:06:29 -0500 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_009F_01C23B10.1C11F690"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2600.0000 This is a multi-part message in MIME format. ------=_NextPart_000_009F_01C23B10.1C11F690 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.emedicine.com/oph/topic115.htm eMedicine - Ocular Rosacea : Article by J Bradley = Randleman, MD
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Ocular Rosacea


Synonyms, Key=20 Words, and Related Terms: rosacea, adult acne=20
Home | Search | Contents | A-Z=20 Index | Tools | Updates | Medline | Cover | Dictionary | GetCME | Rate this topic | Help
 eMedicine Journal = > Ophthalmology > = Dermatologic = Disorders > Ocular = Rosacea=20
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AUTHOR INFORMATION = Section 1 of 11    <= IMG=20 height=3D10 alt=3D"Click here to go to the next section in this = topic"=20 src=3D"http://www.emedicine.com/images/next3.gif" width=3D31 = align=3Dmiddle=20 border=3D0>

Authored by = J Bradley Randleman, MD, Staff Physician, Department of = Ophthalmology, Emory University School of Medicine

Coauthored by C Diane Song, MD, Assistant Professor, = Department of Ophthalmology, Emory University

J Bradley Randleman, MD, is a member of the following medical = societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, and = American Society of Cataract and = Refractive=20 Surgery

Edited by Fernando H Murillo-Lopez, MD, Instructor,=20 Department of Ophthalmology, Bolivian National Institute of = Ophthalmology;=20 Francisco Talavera, PharmD, PhD, Senior Pharmacy = Editor,=20 eMedicine; Christopher J Rapuano, MD, Co-Chairman of = Refractive=20 Surgery Department, Associate Professor, Cornea Service, Wills Eye = Hospital,=20 Jefferson Medical College; Lance L Brown, OD, MD,=20 Ophthalmologist, Regional Eye Center, Affiliated With Freeman Hospital = and St=20 John's Hospital, Joplin, Missouri; and Hampton Roy, Sr, = MD,=20 Clinical Associate Professor, Department of Ophthalmology, University of = Arkansas for Medical Sciences=20

Author's = Email: J=20 Bradley Randleman, MD 3D"Click
Editor's = Email: Fernando=20 H Murillo-Lopez, MD

eMedicine Journal, August 16 2001, Volume 2, = Number=20 8
INTRODUCTION = Section 2 of 11    3D"Click

Background= :=20 Rosacea is a dermatologic condition that affects the midfacial = region=20 (in the form of telangiectasias, erythema, papules and pustules, and = rhinophyma)=20 and, in many instances, the eye. Ocular manifestations are essentially = confined=20 to the eyelids and ocular surface; problems range from minor irritation = to=20 potentially severe ocular surface disruption and inflammatory keratitis. = This=20 keratitis can result in sterile corneal ulceration and eventual = perforation if=20 not treated aggressively. The symptoms of rosacea can be treated = effectively;=20 however, rosacea is a chronic condition with exacerbations and = remissions, which=20 requires long-term therapy to maintain symptomatic control.

Pathophysiology: The precise pathophysiology of = rosacea=20 remains unknown. Rosacea manifests itself primarily as a cutaneous = vascular=20 disorder; however, inflammatory changes are a hallmark of severe = rosacea. Thus,=20 rather than a specific disease entity, rosacea may be thought of as a = disease=20 spectrum with 2 primary etiologic components, vascular and inflammatory. = The=20 earliest manifestations of the disease are cutaneous vascular dilatory = changes=20 with subsequent increased blood flow in the form of telangiectasias and=20 erythema. Sunlight-induced small vessel damage may contribute to this = underlying=20 vascular instability.=20

The later stages of rosacea are marked by inflammatory changes in the = form of=20 papules and pustules in the midface, rhinophyma (bullous nose), = blepharitis and=20 meibomitis, and corneal vascularization. A type 4, cell-mediated=20 hypersensitivity reaction has been hypothesized as a possible mechanism. = Demodex mites also have been implicated as a possible = inflammatory=20 stimulus. Additionally, Helicobacter pylori has been postulated = to be a=20 causative factor in a subset of patients. Whatever the underlying = mechanism,=20 there is a fundamental abnormality in the sebaceous glands of the face = and=20 eyelids, which leads to the inflammatory changes exhibited.

Frequency:

Mortality/Morbidity: Rosacea is not a = life-threatening=20 disease. Approximately 5% of patients with rosacea manifest corneal = disease,=20 which may be severe and can lead to blindness via corneal ulceration,=20 perforation, secondary infections, or corneal opacification from = complete=20 vascularization.=20

Race: Rosacea is recognized much more commonly in=20 fair-skinned Caucasian patients but also occurs in other populations and = actually may be underreported, rather than less prevalent, in races with = increased skin pigmentation.=20

Sex: Females are affected twice as commonly as = males;=20 however, disease manifestations, especially rhinophyma, often are more = severe in=20 males.=20

Age: All ages can be affected, including pediatric = patients.=20 Peak incidence occurs in the fourth to seventh decades.
CLINICAL Section 3 of 11   <= IMG=20 height=3D10 alt=3D"Click here to go to the previous section in = this topic"=20 src=3D"http://www.emedicine.com/images/back3.gif" width=3D31 = align=3Dmiddle=20 border=3D0> =

History:=20

  • Facial symptoms
    • Recurrent flushing episodes
    • Persistent and/or recurrent midfacial erythema
    • Acne (adult onset)
  • Ocular symptoms
    • Dry eyes, irritation, redness, itching, burning, foreign body = sensation,=20 photophobia
    • Recurrent "styes"
    • Recurrent eye infections

Physical:

  • Facial findings
    • Telangiectasias
    • Papules and pustules (without comedones)
    • Rhinophyma (hypertrophy of sebaceous glands of the nose leading = to=20 bullous tissue hyperplasia)
  • Ocular findings
    • Eyelid (most common)=20

      • Eyelid telangiectasias
      • Blepharitis
      • Meibomian gland dysfunction
      • Thick viscous plugging of meibomian gland orifices
      • Hordeola/chalazia
    • Conjunctivitis=20

      • Usually chronic, diffuse hyperemia
      • Can in rare, severe cases lead to=20 cicatrization
    • Corneal findings=20

      • Punctate epithelial keratopathy (PEK) usually in the inferior = one=20 third of the cornea
      • Marginal corneal infiltrates
      • Corneal neovascularization
      • Superficial, wedge-shaped peripheral vascularization with its = base at=20 the limbus
      • Can progress to frank corneal neovascularization and eventual=20 opacification
      • Corneal thinning, ulceration, and=20 perforation
    • Secondary bacterial keratitis
    • Episcleritis, scleritis (rare)

Causes:

  • Flushing triggers - Alcohol, hot beverages, tobacco, spicy foods,=20 stress
  • Sunlight - Postulated to decrease the competence of already = dilated=20 cutaneous vasculature
  • Demodex - Postulated to increase the inflammatory = reaction of the=20 sebaceous glands
  • H pylori - Postulated to be correlated strongly with = rosacea=20 (This possibly is due to a flush-inducing toxin present in H=20 pylori.)
DIFFERENTIALS = Section 4 of 11   3D"Click

Blepharitis, Adult=20
[Central Corneal Ulceration]

Chalazion
Chlamydia
Cicatricial Pemphigoid =
Conjunctivitis,=20 Allergic
Conjunctivitis, = Bacterial=20
Conjunctivitis, Viral=20
Corneal = Erosion,=20 Recurrent
Dermatitis, Atopic =
Dry Eye Syndrome =
Episcleritis =
Keratitis, Bacterial =
Keratoconjunctivitis, = Atopic=20
Keratoconjunctivitis, = Sicca=20
Ulcer, = Corneal=20


WORKUP Section 5 of 11   =

Lab Studies:

Histologic Findings: Skin and = conjunctival=20 specimens have shown a nonspecific collection of inflammatory cells, = increased=20 vascular dilatation, and occasionally granulomatous changes. None of = these=20 changes are specific for rosacea.

TREATMENT Section 6 of 11   

Medical = Care:=20 Rosacea is an enigmatic disease with multiple exacerbations and = remissions, and treatment unfortunately is directed toward symptomatic = control=20 rather than cure. Ocular rosacea can manifest as minor ocular irritation = or=20 severe corneal compromise; thus, medical therapy is chosen based on the = severity=20 of presentation. When possible, a stepwise approach can be undertaken, = using=20 first lid hygiene and artificial tears, followed by topical and oral=20 anti-inflammatory medications, with late surgical intervention as = required.=20

As can be implied by the number and variety of treatment options = available=20 for rosacea, no one therapeutic regimen has been found effective in all = cases,=20 and many cases of rosacea are recalcitrant to multiple therapies. = Therefore,=20 treatment always must be tailored to each individual, and various = options must=20 be explored until symptoms begin to respond favorably.

  • Artificial tears: Because of the frequency of application, = nonpreserved=20 artificial tears are recommended for use. Tears should be applied = liberally=20 throughout the day, and, if necessary, a lubricating ointment may be = used at=20 night. This ointment may contain an antibiotic preparation.
  • Antibiotics=20

    • Tetracyclines (tetracycline, doxycycline, minocycline)=20

      • Tetracyclines represent the most common and most effective = treatment=20 regimen for rosacea. These drugs are believed to be effective not=20 primarily as antibiotics but rather through a secondary effect = that they=20 exert on the meibomian glands. Tetracyclines decrease bacterial = lipase,=20 thereby altering the fatty acid composition of the meibomian gland = secretions and improving their solubility. These medications also = inhibit=20 collagenase; therefore, they are effective in protecting the = cornea from=20 impending perforation secondary to inflammatory responses.=20

      • Adverse effects are predominantly gastrointestinal, including = diarrhea=20 and rarely pancreatitis and pseudomembranous colitis. More severe = but much=20 less common adverse effects include benign intracranial = hypertension and=20 renal tubular damage (Fanconi syndrome) from outdated medications. = Additionally, tetracyclines cross the placenta and can cause = permanent=20 discoloration of teeth as well as retardation of fetal bone = growth.=20

      • Tetracyclines generally are effective for rosacea in doses = much lower=20 than those given for antibiotic effect, and, once the disease has = come=20 under control, the dose may be tapered to a lower, suppressive = dose and=20 maintained indefinitely. Due to the chronic, relapsing nature of = rosacea,=20 the medication may be used chronically at suppressive doses or=20 discontinued and restarted if and when symptoms recur.=20

      • Among this class of medications, tetracycline and doxycycline = most=20 commonly are used. The 2 medications are quite similar in their = mechanism=20 of action, side effect profile, and efficacy, but slight = differences do=20 exist. Tetracycline has a shorter half-life and, thus, is dosed 4 = times=20 per day, as opposed to doxycycline, which is given twice per day = or once=20 per day. Frucht-Pery et al reported a more rapid therapeutic = response to=20 tetracycline; however, no difference was found at 6 months. = Additionally,=20 the side effects profile is slightly more favorable for=20 doxycycline.

    • Erythromycin can be taken orally for patients intolerant to, or = too=20 young for, tetracyclines. Erythromycin ointment applied to the lid = margins=20 once or twice daily can provide lubrication for the eye and reduce = the=20 bacterial overgrowth contributing to lid margin disease.=20

    • Clarithromycin has shown efficacy in treating rosacea. This = compound=20 exhibits anti-inflammatory effects as well as activity against H = pylori. Torresani compared clarithromycin and doxycycline and = found=20 equivalent therapeutic responses and a milder side effect profile = for=20 clarithromycin.=20

    • Metronidazole=20

      • Metronidazole exhibits antimicrobial (antibacterial and=20 antiparasitic), anti-inflammatory, and immunosuppressive = properties and=20 has been found effective against rosacea. Oral metronidazole has = in fact=20 been advocated as first-line therapy. Adverse effects include=20 gastrointestinal irritation and a disulfiramlike action; thus, = abstinence=20 from alcohol is required.=20

      • Topical metronidazole is quite effective in treating skin = lesions in=20 rosacea. While not approved for ophthalmic use, in a pilot study,=20 Barnhorst et al found the topical compound to be safe and = effective in=20 treating eyelid involvement in ocular = rosacea.
  • Topical steroids can prove useful for short-term exacerbations of = lid=20 disease and management of inflammatory keratitis. However, steroids = should be=20 used cautiously and discontinued as soon as possible to prevent = corneal=20 melting.
  • Retinoids: Vitamin A derivatives, such as oral isotretinoin and = topical=20 tretinoin, have been found effective in reducing the inflammatory = lesions in=20 rosacea. This appears to be accomplished via the suppression of sebum=20 production and a subsequent reduction in sebaceous follicle size.=20 Additionally, tretinoin may help restore sun-damaged skin through the=20 increased production of type 1 collagen in damaged regions. Both = compounds=20 actually can cause severe erythema and blepharoconjunctivitis, worsen=20 telangiectasias, and lead to severe keratitis. Additionally, retinoids = are=20 extremely teratogenic and, thus, must never be used during pregnancy.=20 Therefore, the use of retinoids commonly is reserved for cases in = which=20 multiple agents have failed.
  • Antiulcer therapy: H pylori plays an as yet undetermined = role in=20 rosacea, and some have advocated H pylori eradication in = treatment of=20 rosacea. Thus, in some cases of rosacea, antiulcer combination = regimens, such=20 as amoxicillin or clarithromycin, metronidazole, bismuth, and an H2 = antagonist=20 have been used with varying efficacy.

Surgical Care:

  • Treatment of dry eye: Punctal occlusion can be accomplished via = permanent=20 silicone plugs or punctal cauterization.
  • Treatment of corneal perforations
    • Cyanoacrylate tissue adhesive
    • Lamellar keratoplasty
    • Penetrating keratoplasty
  • Restoration of vision from corneal disease
    • Penetrating keratoplasty
    • The success rate for graft survival generally is much lower than = for=20 noninflammatory conditions due to the increased vascularization of = the host=20 cornea.

Consultations: A consult with dermatology is = essential for=20 optimal management of rosacea.

Diet: Avoidance of trigger foods and beverages can = reduce=20 symptomatic episodes.

Activity: Avoidance of sunlight can benefit some = patients.
MEDICATION = Section 7 of 11   

The goals = of=20 pharmacotherapy are to reduce morbidity and to prevent = complications.

Drug Category: Antibiotics -- = Anti-inflammatory=20 effect helps to ameliorate meibomian gland disease.
Drug Name
 Tetracycline (Sumycin) -- = Inhibits=20 bacterial protein synthesis by binding with 30S and possibly 50S = ribosomal=20 subunit(s). Has anti-inflammatory activity. Also a potent = collagenase=20 inhibitor.
Adult Dose 250 mg PO qid
Pediatric Dose <8 years: Not = recommended
>8=20 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid
Contraindications Documented hypersensitivity; = use with=20 caution in patients with renal impairment
Interactions Bioavailability decreases with = antacids=20 containing aluminum, calcium, magnesium, iron, or bismuth = subsalicylate;=20 can decrease effects of oral contraceptives, causing breakthrough = bleeding=20 and increased risk of pregnancy; tetracyclines can increase=20 hypoprothrombinemic effects of anticoagulants
Pregnancy D - Unsafe in pregnancy=20
Precautions Photosensitivity may occur with = prolonged=20 exposure to sunlight or tanning equipment; reduce dose in renal=20 impairment; consider drug serum level determinations in prolonged = therapy;=20 tetracycline use during tooth development (last one half of = pregnancy=20 through age 8 y) can cause permanent discoloration of teeth; = Fanconilike=20 syndrome may occur with outdated = tetracyclines
Drug Name
 Doxycycline (Bio-Tab, = Vibramycin, Doryx)=20 -- DOC; inhibits bacterial protein synthesis by binding with 30S = and=20 possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. = Also a=20 potent collagenase inhibitor.
Adult Dose 100 mg PO qd/bid, can taper to = 50 mg qd=20 or qod
Pediatric Dose 2.2 mg/kg PO qd/bid
Contraindications Documented hypersensitivity
Interactions Bioavailability decreases with = antacids=20 containing aluminum, calcium, magnesium, iron, or bismuth = subsalicylate;=20 can decrease effects of oral contraceptives, causing breakthrough = bleeding=20 and increased risk of pregnancy; tetracyclines can increase=20 hypoprothrombinemic effects of anticoagulants; concurrent use of = vitamin A=20 has been associated with increased intracranial pressure; antacids = decrease the absorption of tetracyclines
Pregnancy D - Unsafe in pregnancy=20
Precautions Photosensitivity may occur with = prolonged=20 exposure to sunlight or tanning equipment; reduce dose in renal=20 impairment; consider drug serum level determinations in prolonged = therapy;=20 tetracycline use during tooth development (last one half of = pregnancy=20 through age 8 y) can cause permanent discoloration of teeth; = Fanconilike=20 syndrome may occur with outdated tetracyclines; caution in = patients with=20 hepatic insufficiency
Drug Name
 Clarithromycin (Biaxin) -- = Inhibits=20 bacterial growth, possibly by blocking dissociation of peptidyl = t-RNA from=20 ribosomes causing RNA-dependent protein synthesis to arrest. = Effective=20 through secondary, anti-inflammatory action.
Adult Dose 250-500 mg PO bid
Pediatric Dose 7.5 mg/kg PO bid
Contraindications Documented hypersensitivity;=20 coadministration of pimozide
Interactions Toxicity increases with = coadministration=20 of fluconazole and pimozide; clarithromycin effects decrease and = GI=20 adverse effects may increase with coadministration of rifabutin or = rifampin; may increase toxicity of anticoagulants, cyclosporine,=20 tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids,=20 triazolam, HMG CoA-reductase inhibitors; plasma levels of certain=20 benzodiazepines may increase, prolonging CNS depression; = arrhythmias and=20 increase in QTc intervals occur with disopyramide; = coadministration with=20 omeprazole may increase plasma levels of both agents
Pregnancy C - Safety for use during = pregnancy has=20 not been established.=20
Precautions Coadministration with = ranitidine or=20 bismuth citrate is not recommended with CrCl <25 mL/min; give = half dose=20 or increase dosing interval if CrCl <30 mL/min; diarrhea may be = sign of=20 pseudomembranous colitis; superinfections may occur with prolonged = or=20 repeated antibiotic therapies
Drug Name
 Metronidazole (Flagyl, = Protostat) -- Has=20 anti-inflammatory and immunosuppressive activity.
Adult Dose 250-500 mg PO bid/qid
Pediatric Dose 7.5 mg/kg PO bid/qid
Contraindications Documented hypersensitivity
Interactions Concurrent use with warfarin = results in=20 increased warfarin activity; concurrent use with cimetidine = results in=20 increased metronidazole levels; concurrent use with disulfiram = results in=20 combined toxicity
Pregnancy B - Usually safe but benefits = must=20 outweigh the risks.=20
Precautions Extended use has been = associated with the=20 development of peripheral neuropathy, seizures, pancreatitis, = leukopenia,=20 and Clostridium difficile colitis
Drug Name
 Erythromycin ophthalmic = ointment=20 (E-Mycin) -- Used to decrease meibomian gland bacterial = overgrowth.
Adult Dose Apply qhs/bid to eyelid margins
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy B - Usually safe but benefits = must=20 outweigh the risks.=20
Precautions Prolonged use may result in = overgrowth=20 of
nonsusceptible organisms, including fungi; discontinue = use at=20 first appearance of a skin rash or any other sign of = hypersensitivity=20 reaction
Drug Category: = Retinoids=20 -- Decrease sebaceous gland size and sebum production. May = inhibit=20 sebaceous gland differentiation and abnormal keratinization.
Drug Name
 Isotretinoin (Accutane) -- = Reduces sebum=20 production and sebaceous follicle size.
Adult Dose 0.5-1 mg/kg/d divided bid
Pediatric Dose Not recommended
Contraindications Documented hypersensitivity; = females of=20 childbearing age (has been shown to cause major fetal = abnormalities)
Interactions Concurrent use with = tetracyclines results=20 in an increased risk for the development of pseudotumor cerebri;=20 contraindicated with concurrent use of other topical acne = medications
Pregnancy X - Contraindicated in = pregnancy
Precautions Do not donate blood while = taking=20 medication or within 30 d of discontinuing its use to prevent = possible=20 exposure for pregnant women; has been shown to cause corneal = opacities and=20 potentially severe blepharoconjunctivitis; has been shown to cause = nosebleeds; can result in significant GI disturbances leading to=20 discontinuation of use; exhibits cross-sensitivity with other = vitamin A=20 derivatives
Drug Name
 Tretinoin (Avita, Retin-A) -- = Reduces=20 sebum production and sebaceous follicle size. May help restore = sun-damaged=20 skin.
Adult Dose Apply qd/bid
Pediatric Dose <12 years: Not=20 recommended
>12 years: Administer as in adults
Contraindications Documented hypersensitivity; = use with=20 other retinoids; use with other topical acne medications or = astringents
Interactions None reported
Pregnancy C - Safety for use during = pregnancy has=20 not been established.=20
Precautions Discontinue if severe burning, = stinging,=20 or erythema develops; avoid unnecessary sun exposure; use of = medication=20 may worsen telangiectasias; exhibits cross-sensitivity to other = vitamin A=20 derivatives
Drug Category: = Steroids=20 -- Topical steroids occasionally are needed to help suppress = inflammatory=20 changes in the cornea.
Drug Name
 Prednisolone acetate (Pred = Forte) --=20 Decreases inflammation and corneal neovascularization. Suppresses=20 migration of polymorphonuclear leukocytes and reverses increased = capillary=20 permeability.
Adult Dose 1 gtt q1-12h based on severity = of=20 inflammation
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity; = viral,=20 fungal, or tubercular infections
Interactions None reported
Pregnancy C - Safety for use during = pregnancy has=20 not been established.=20
Precautions Can increase corneal thinning = and melting=20 and lead to globe perforation; monitor IOP carefully, and = discontinue=20 topical steroids if an acute rise in pressure noted; discontinue = steroids=20 at first sign of active ocular surface = infection
FOLLOW-UP Section 8 of 11    =

Further Inpatient Care:

  • Inpatient care is rarely necessary except in some cases of corneal = perforations or severe secondary corneal infections.

Further Outpatient Care:

  • Long-term management by both dermatology and ophthalmology is = necessary to=20 control this disease. Visits may be frequent in the beginning to gain = control=20 over symptoms or protect an endangered cornea.

In/Out Patient Meds:

  • Lid hygiene
  • Artificial tears
  • Oral antibiotics - Doxycycline, tetracycline, clarithromycin, or=20 metronidazole
  • Consider erythromycin ointment.
  • Consider topical metronidazole.
  • Consider topical steroids.

Deterrence/Prevention:

  • Patients should avoid trigger foods and situations.
  • For some patients avoidance of sunlight can minimize = flare-ups.

Complications:

  • Complications include corneal vascularization, ulceration, = perforations,=20 secondary bacterial infections, and, ultimately, decreased = vision.
  • Eyes undergoing penetrating keratoplasty are more likely to = experience=20 graft rejection than eyes without rosacea because of the increased=20 inflammatory response and relatively increased corneal = vasculature.

Prognosis:

  • Rosacea can be controlled symptomatically but is generally a = chronic=20 condition, which requires long-term care and follow-up care.

Patient Education:

  • It is critical to inform patients of the chronic, relapsing nature = of this=20 disease so that patient expectation matches available therapy and so = that=20 patient follow-up care is maximized. Additionally, ophthalmologists = probably=20 underdiagnose rosacea due to a lack of familiarity with the = dermatologic=20 manifestations of the disease.
MISCELLANEOUS = Section 9 of 11    3D"Click

Medical/Legal Pitfalls:

  • Failure to recognize, diagnose, and treat rosacea can compromise = the=20 integrity of the ocular surface.

Special Concerns:

  • Because rosacea is a chronic, often progressive disease, patients = are=20 likely to become increasingly symptomatic as they age.
  • Patients need to understand that this is a chronic condition, = requiring=20 long-term treatment.
PICTURES Section 10 of 11   = <= IMG=20 height=3D10 alt=3D"Click here to go to the next section in this = topic"=20 src=3D"http://www.emedicine.com/images/next3.gif" width=3D31 = align=3Dmiddle=20 border=3D0>

Caption: Picture = 1. Typical=20 dermatologic findings of rosacea, including midfacial papules, = pustules,=20 and rhinophyma
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
Caption: Picture = 2. Typical=20 findings of rosacea, including papules, pustules, and rhinophyma =
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
Caption: Picture = 3. Eyelid=20 telangiectasias with inspissated meibomian glands
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
Caption: Picture = 4.=20 Peripheral corneal pannus
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
Caption: Picture = 5.=20 Extensive corneal pannus with thinning
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
Caption: Picture = 6.=20 Extensive corneal neovascularization and opacification
3D"Click 3D"ClickView Full Size=20 Image
3D"ClickeMedicine Zoom=20 View (Interactive!)
Picture Type:=20 Photo
BIBLIOGRAPHY = Section 11 of 11   3D"Click

NOTE:
Medicine is a constantly = changing=20 science and not all therapies are clearly established. New = research=20 changes drug and treatment therapies daily. The authors, editors, = and=20 publisher of this journal have used their best efforts to provide=20 information that is up-to-date and accurate and is generally = accepted=20 within medical standards at the time of publication. However, as = medical=20 science is constantly changing and human error is always = possible,=20 the authors, editors, and publisher or any other party involved = with the=20 publication of this article do not warrant the information in this = article=20 is accurate or complete, nor are they responsible for omissions or = errors=20 in the article or for the results of using this information. The = reader=20 should confirm the information in this article from other sources = prior to=20 use. In particular, all drug doses, indications, and = contraindications=20 should be confirmed in the package insert. FULL = DISCLAIMER=20
eMedicine Journal,=20 August 16 2001, Volume 2, Number 8

Ocular = Rosacea=20 excerpt

=A9 Copyright 2002, eMedicine.com,=20 Inc.=20
 eMedicine Journal = > Ophthalmology > = Dermatologic = Disorders > Ocular = Rosacea=20
Home | Search | Contents | A-Z=20 Index | Tools | Updates | Medline | Cover | Dictionary | GetCME | Rate this topic | Help
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