1.11 Ocular Rosacea

Date of last review:

19/12/2025

Date of next review:

19/12/2027

Date of publication:

19/1/2026

This is a GOS Specialist Supplementary condition and should be managed by community optometrists in line with national guidance⁽⁸⁾. This guideline should be read in conjunction with ‘Supporting information’ guidance [link to Supporting Information page]

Differential diagnosis ⁽¹⁾

Tear deficiency
Interstitial/infectious keratitis
Other chronic blepharitis causes

Possible management by optometrist

Advice ⁽¹⁾

Identify and avoid triggers (e.g. facial flushing)
Consider Omega-3 supplementation

Treatment

Ocular lubricants for symptomatic relief as required (drops/gel for use during the day ± unmedicated ointment for use at bedtime)⁽¹⁾. Refer to local formularies for suitable options⁽⁶⁾
Blepharitis management (lid hygiene, warm compresses) ⁽¹⁾
Manage associated conditions (chalazion, hordeolum, posterior blepharitis, tear deficiency) ⁽¹⁾
Topical antibiotics (e.g. azithromycin, off-label) ⁽¹⁾
Oral tetracyclines (e.g. doxycycline) ⁽¹⁾
- Alternatives if contraindicated (e.g. oral erythromycin) ⁽¹⁾
- NB: Oral antibiotics ideally after confirmed cutaneous rosacea diagnosis ⁽¹⁾
Short-term mild topical steroids for exacerbations (if no corneal ulceration) ⁽¹⁾
- Monitor intraocular pressure at baseline, 2 weeks, then every 4 weeks for 2–3 months ⁽¹⁾
IPL therapy: evidence for effectiveness/safety is lacking (2020 Cochrane Review) ⁽¹⁾
Consider co-management with dermatologist or GP (see ‘Supporting information’ [link to Supporting Information page]) ⁽⁷⁾

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Oral Doxycycline tablets/capsules ^(1,5) (POM): 100mg once daily for 2-3 months ⁽⁶⁾
Oral Erythromycin tablets ^(1,5) (POM): 500mg twice daily for 2-3 months ⁽⁶⁾
Azithromycin 15mg/ml eye drops ^(1,5)(POM, off label): One drop twice daily for 3 days ^(2,3)
Fluorometholone (FML) 0.1% eye drops ^(1,5)(POM): One drop ⁽⁷⁾, two to four times daily. For more serious conditions apply every 1 hour for 24-48 hours, then reduce to two to four times daily ^(2,3). Duration will depend on severity of the condition and may require tapering ⁽⁶⁾.

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Normally no referral ⁽¹⁾. GOS Specialist Supplementary Stage 1 where appropriate* ⁽⁸⁾
If required, GOS Specialist Supplementary Stage 2* treatment should be provided by a local IP optometrist/OMP who is registered and qualified to carry out GOS Specialist Supplementary Stage 2 management; intra-referral (practice to practice) should take place to facilitate this ⁽⁸⁾
Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate (outwith GOS Specialist Supplementary) ⁽⁷⁾
If keratitis is severe or not responding to treatment, refer urgently to ophthalmology ⁽¹⁾

*Treatment should be provided in line with “Annex C of the Statement” ⁽⁸⁾

https://www.eyes.nhs.scot/for-professionals/legislation/

Possible management in secondary care or local/community pathways where available ^(1,8)

See Further management options
Secondary care options:
- dermatology/ophthalmology co-management
- topical ciclosporin (unlicensed)
- topical ivermectin (eyelid skin)
- topical steroid for management of severe corneal disease
- surgical intervention for severe corneal disease

College of Optometrists Clinical Management Guideline⁽¹⁾

Ocular rosacea - College of Optometrists*

*With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation, and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways.

Users should note that Guidelines which have not yet been updated should be considered with caution. Where the Eyecare Guidelines contain links to other sites and/or resources provided by third parties, these links are provided for information only.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines are made available on the basis of excluding all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Eyecare Guidelines.

CEG disclaimer for updated guidelines:

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

While the Common Services Agency (“NSS”) makes reasonable efforts to ensure that the information on the Eyecare Guidelines area of the Website is correct, the Website is provided ‘as is’ and NSS does not warrant the accuracy and completeness of the material on the Website. NSS may make changes to the Website at any time without notice. Some of the material on the Website may be out of date, and NSS makes no commitment to update such material. Users should note that some Eyecare Guidelines on the Website have not been updated for several years and should be considered with caution.

Where the Eyecare Guidelines section of the Website contains links to other sites and or resources provided by third parties, these links are provided for information only. NSS has no control over, and no liability in respect of, the content of these sites and resources.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines area of the Website is made available by NSS on the basis that NSS excludes all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Website. 