Ocular Rosacea Often Goes Underdiagnosed, Study Finds

A new systematic review and meta-analysis highlights significant variability in the reported prevalence of ocular rosacea, particularly among patients with cutaneous rosacea. With the ocular form often presenting without visible skin symptoms, the study emphasizes the urgent need for consistent diagnostic criteria, increased clinician awareness and timely referrals to prevent complications and ensure early intervention in patients with nonspecific ocular complaints. Photo: Christine Sindt, OD. Click image to enlarge. The inflammatory skin condition rosacea affects approximately 5% of the population. Patients frequently present with facial flushing and erythema symptoms, but it can also cause ocular manifestations such as lid telangiectases, corneal infiltrates, scleritis/sclerokeratitis and dry eye symptoms. However, the presence of cutaneous rosacea (CR) is not necessary to diagnose ocular rosacea (OR), leading to potential underdiagnoses. In order to get a clearer picture on the prevalence of diagnosed cases of OR within the CR population, a group of researchers conducted a systematic review and meta-analysis, the results of which were recently published in Canadian Journal of Ophthalmology. According to the study, there is substantial variability in the reported prevalence of diagnosed ocular rosacea, bringing to light the need for greater clinician awareness and improved referral guidelines.This meta-analysis encompassed a total of 28 studies, 11 of which included 124,093 individuals diagnosed with ocular rosacea, and another 17 studies with 1,747 individuals who had ocular involvement in cutaneous rosacea. Prevalence of diagnosed OR was 10.3%, whereas the prevalence of ocular involvement in CR was 44.3%. Previous reports estimated the prevalence of diagnosed ocular rosacea from 0.61% to 65.1%. The study authors say this may be due to the variation in the way ocular rosacea is diagnosed across studies, as some defined it based on prescribed hypromellose eye drops, while others determined the diagnosis through private health care claims or ophthalmic signs and symptoms.A lack of clear guidelines on when to refer patients with cutaneous rosacea to ophthalmology contributes to this disparity, the authors wrote in their study. In the case of any suspected ocular involvement, primary care providers should refer promptly to an eyecare provider for examination “to avoid delays in management and prevent severe sequelae of the disease,” they wrote.Instances where ocular rosacea presents prior to or without any signs of CR represents a unique management challenge in the clinical setting. “For instance, it is not uncommon for patients with idiopathic dry eye to present with non-specific symptoms similar to OR, such as foreign body sensation, burning, dryness and itching,” wrote the authors in CJO. “Given CR can be relapsing and remitting and ocular symptoms can occur in the absence of cutaneous disease, clinicians of all specialties are urged to ask patients presenting with nonspecific ocular concerns about risk factors for rosacea, any history of rosacea or rosacea-like signs and symptoms.”Interestingly, the present study revealed that publication year contributed significantly to the prevalence of OR in CR, but not ocular involvement. In particular, older studies showed a higher prevalence than recent ones. Researchers say this might be due to changes in ocular rosacea diagnosis guidelines, diagnostic techniques or varied understandings of the disease over time. In 2002, the United States National Rosacea Society published standardized diagnostic guidelines for all rosacea subtypes, including ocular rosacea. These were later updated in 2017, and continue to be widely referenced, however, according to the authors, there does not appear to be widespread uptake and application of their use in research, possibly leading to heterogenous methods of OR diagnosis across studies.In regards to limitations, there was a lack of data on skin type, disease severity, ethnicity and disease duration, making it difficult for researchers to determine whether a diversity of skin colors was represented, potentially limiting the generalizability of these findings. “This is relevant, as evidence suggests rosacea might be underdetected and misdiagnosed in those with richly pigmented skin, due to masking of erythema,” wrote the authors.These findings underscore the importance of recognizing ocular involvement in patients with diagnosed cutaneous rosacea, as it may be more prevalent than diagnosed, concluded the authors. “Clear guidelines for diagnoses and referral are needed,” they wrote. “The ophthalmologist should consider a diagnosis of OR in patients with risk factors or prior history of CR, presenting with nonspecific ophthalmic signs and symptoms such as dry eye. Future research should address gaps in prevalence data by CR subtypes, and explore the impact of skin type.”Click here for the journal source. Kirkpatrick RH, et al. Prevalence of ocular manifestations in cutaneous rosacea: Systematic review and meta-analysis. Canadian Journal of Ophthalmology. June 6, 2025. [Epub ahead of print.]