Rosacea is a dermatological condition, secondary to immunological and vascular dysfunction, that affects the pilosebaceous regions of the face and the eye (Weidmayer, 2015; Vieira et al, 2012). Although the primary ocular manifestations involve the lids, including meibomian gland dysfunction (MGD) and telangiectasias, the corneal tissue can become involved secondary to inflammation. Ocular rosacea can be particularly problematic for contact lens patients and can result in dry eye and lens intolerance.

A Sample Case

A 50-year-old male keratoconus patient was urgently seen for bilateral onset of irritation, redness, and photophobia, which he reported worsened with scleral lens wear. His previous appointment 10 months prior was unremarkable. His visual acuity was OD 20/50 and OS 20/40.

Slit lamp findings included bilateral conjunctival injection and superior corneal vascularization (Figure 1), with terminal infiltrates OD without stain. The patient was referred to a corneal specialist who initially prescribed steroid drops. After follow-up visits and after ruling out superior limbic keratitis, he was diagnosed with ocular rosacea resulting in telangiectasia of the lids, MGD, and corneal neovascularization. The steroids were tapered, and he was prescribed cyclosporine drops and oral doxycycline. This treatment regimen dramatically improved his symptoms and reduced his neovascularization (Figure 2) so that he was able to return to safe, comfortable scleral lens wear.

Signs and Symptoms

Signs of ocular rosacea, which can precede facial sequelae in 20% of patients (Ghanem et al, 2003), commonly include blepharitis, MGD, and telangiectasia. Local flora and Demodex are thought to be contributing factors of rosacea (Weidmayer, 2015). Although corneal involvement is less common, its consequences can be much more severe. Untreated corneal vascularization and inflammation can result in ulceration and perforation (Vieira et al, 2012). Although signs of corneal involvement are easily identified, they are not always matched up with a diagnosis of ocular rosacea. This can especially be the case if the patient is wearing contact lenses.

Differential diagnosis could include inflammatory events directly related to contact lens overwear or to solution hypersensitivity. Additionally, landing zone compression, poor limbal-lens fitting relationship, or reduced transmissibility can complicate the differential diagnosis, delaying selective treatment.

End Results

Treatment of this patient’s vascular keratitis was primarily directed at reducing inflammation. Topical steroids improved his symptoms, followed by the addition of topical cyclosporine for safer longer-term management. The antibiotic and anti-inflammatory properties of doxycycline contributed to resolution. CLS

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