Date of last review: Due to be updated

Differential diagnosis

  • Tear deficiency
  • Interstitial keratitis
  • Infectious keratitis
  • Other causes of chronic blepharitis

Possible management by Optometrist

Treatment

  • Ocular lubricants for tear deficiency/instability related symptoms (drops for use during the day, unmedicated ointment for use at bedtime)
  • Treat associated posterior blepharitis
  • PoM Antibiotics require co-management with GP- tetracyclines contra-indicated in children, pregnant women, breast-feeding women
    • PoM Topical Metronidazole 0.75% gel (adults over 18 years) applied thinly twice daily to face and eyelids for 6 to 9 weeks, then intermittently
      • Review at 6 to 9 weeks
      • If effective options, depending on patient preference, are:
        • Stop treatment and review regularly
        • Tail treatment off
          • Reduce frequency to alternate days, then twice weekly
          • Long term intermittent maintenance may be required
        • If ineffective consider oral antibiotic
      • PoM Doxcycline (adults over 18 years) 100mg once daily for up to 3 months, repeated courses may be necessary
      • Or PoM Erythromycin (adults over 18 years), if tetracyclines contraindicated, 500mg twice a day for up to 3 months; repeated courses may be necessary
        • Review at 3 months
        • If effective options, depending on patient preference, are
          • Stop treatment and review regularly
          • Tail treatment off then stop
            • Halve dose for 2-6 months
            • Long term intermittent maintenance may be required
          • Switch to Topical Metronidazole 0.75% gel

Advice

  • Explain rosacea is an idiopathic long-term skin condition, which comes and goes
    • It causes inflammation of the skin of the face and the eyelids, particularly cheeks, forehead and chin
    • Swelling of the nose (rhinophymoma), a complication that patients often fear, is uncommon, especially in women, and treatable
    • Rosacea is not caused by poor hygiene or excess alcohol intake
  • Facial flushing and skin irritation may be triggered by extremes of temperature, sunlight, strenuous exercise, stress, spicy foods, caffeine, cheese, alcohol, and hot drinks
  • Wear a broad-brimmed hat to protect the face when going out in the sun
  • Use a high-factor sunscreen (sun-protection factor 30 or more) to the face and eyelids 15 to 30 minutes before going out in the sun and every 2 hours thereafter
  • Advise the use of hypoallergenic emollients If the skin is dry
  • British Association of Dermatologists has useful patient information

Management Category

  • Refer patient to GP, if a new diagnosis
  • Normally no referral to ophthalmology
  • Urgent referral to an ophthalmologist if keratitis is severe

Possible management by Ophthalmologist

  • Topical steroid if no risk of corneal perforation
  • Systemic immunosuppression