|Ahead of print publication
Ocular rosacea and corneal perforation: A rare case report
Sujit Das1, B Pradeep2, Chhanda Mandal2
1 Department of Ophthalmology, JNU Medical College and Hospital, Port Blair, India
2 Department of Dermatology, Port Blair, ANIIMS, Port Blair, India
|Date of Submission||05-Oct-2019|
|Date of Decision||06-Jan-2020|
|Date of Acceptance||03-Mar-2020|
Assistant Professor, Department of Ophthalmology [MS ophthalmology], JNU Medical College and Hospital, Jaipur - 302 017, Rajasthan
Source of Support: None, Conflict of Interest: None
Acne rosacea is a chronic skin condition with exacerbations and remissions, which requires long-term therapy to maintain symptomatic control. Etiology of rosacea is not fully understood and more than 50% of patients with rosacea have ocular manifestations such as blepharitis, conjunctival hyperemia, and rosacea-associated keratitis. Sight-threatening disease is rare with rosacea; however, keratitis can result in corneal ulceration and eventual perforation if not treated aggressively. Here, in my case, there is acne rosacea associated with blepharitis, dryness, peripheral keratitis, and eventually landed up with corneal perforation which then managed with corneal grafting.
Keywords: Acne rosacea, keratitis, ocular rosace and corneal perforation, ocular rosacea
| Introduction|| |
Rosacea is a common inflammatory dermatologic condition that affects the midface and eyes. Although the etiology of rosacea is not fully understood, an augmented response of the innate immune system and neurovascular pathways to certain triggers are considered to be major factors in the chronic inflammatory process associated with this condition. Demodex mites, normal inhabitants of eyelash follicles, may stimulate inflammation in ocular rosacea and anterior blepharitis. Bacteria (staphylococcus epidermidis) may play a role, as ocular rosacea improves with antibiotics. The pro-inflammatory cytokine interleukin 1-alpha increases metallomatrix protein (MMP) in the tear fluid. Upregulation of MMP-9 damages ocular tissues. Obstruction of Meibomian gland More Detailss changes tear film composition, leading to reduced tear film lipid layer, tear film instability, and tear hyperosmolarity. Clinical features include flushing, telangiectasias, erythema, papules and pustules, and rhinophyma. More than 50% of patients with rosacea have ocular manifestations. Manifestations of ocular rosacea range from minor irritation, foreign-body sensation, dryness, and blurry vision to severe ocular surface disruption and inflammatory keratitis. Ocular rosacea is most frequently diagnosed when patients also suffer from the cutaneous disease. However, ocular signs and symptoms may occur before skin manifestations in 20% of patients with rosacea. No correlation exists between the severity of ocular disease and the severity of facial rosacea. Ocular findings include lid margin and conjunctival telangiectasias, eyelid thickening, eyelid crusts and scales, chalazion and hordeolum, punctate epithelial erosions, corneal infiltrates, corneal ulcers, corneal scars, and vascularization. Sight-threatening disease is rare with rosacea; however, keratitis can result in corneal ulceration and eventual perforation if not treated aggressively. Keratitis due to ocular rosacea tends to begin at one edge or the bottom of the eye and then spread to affect the lower half to two-thirds of the cornea. Recurrent attacks lead to corneal thinning, increased corneal opacity, and vessel invasion. Severe ocular disease rarely can result in descemetocele and corneal perforation. Management includes lid hygiene, warm compression to improve the flow of meibomian gland secretions, chalazion, and hordeolum. Artificial tears to reduce symptoms of dry eye. Anterior blepharitis is treated with topical antimicrobials. Topical nonsteroidal anti-inflammatory agents such as ibuprofen and ketorolac may be helpful. Topical steroids are used short-term to treat marked lid inflammation or rosacea keratitis. Long-term use of topical steroids should be avoided, as they can lead to glaucoma and cataracts. Topical ciclosporin is typically used in ocular rosacea that has not responded to topical steroids. Systemic antibiotics such as doxycycline and erythromycin. They reduce bacteria, improve tear film stability, and normalize mebonian gland secretions. Oral antibiotics are generally continued for 6–12 weeks, and then slowly tapered for 1–2 months. Further courses of oral antibiotics can be used for disease flare-ups. Oral omega-3 fatty acid supplementation has been reported to be beneficial for some patients with dry eyes.,, Surgery may be required to repair corneal opacification or perforation due to rosacea keratitis.,
| Case Report|| |
A 28-year-old female a known case of acne rosacea for the past 3 months presented to our outpatient department with complaints of pain, redness, photophobia, and lid swelling for the past 10 days. She was on oral doxycycline and clindamycin gel. She had no known systemic illness, especially diabetes. Skin lesions were papules and pustules involving the mid-face, forehead, and eyelids [Figure 1]. On examination, her visual acuity was 6/6 in both eyes with normal intraocular pressure (14 mmHg in both eyes). There was lid erythema with style formation [Figure 1]. The cornea was lustreless with marginal mid stromal rounded infiltrates [Figure 2]. On fluorescein staining, there was diffuse punctal epithelial keratitis [Figure 3]. Tear film break up time was <10 s indicates dryness. Tear film height was normal (1 mm) [Figure 3]. Schirmer's test showed dry eye [Figure 4]. Conjunctiva was congested with the normal anterior chamber [Figure 5]. There was associated meibomian gland dysfunction [Figure 6]. A diagnosis of ocular rosacea was made and put her on topical antibiotic (chloramphenicol), topical low potency steroid (fluromethelone), and lubricating drop one hourly. Chloramphenicol eye ointment was given at night. Continue oral doxycycline 100 mg twice daily for 8 weeks with Vitamin-C 500 mg four (4) times a day. Simultaneously, hot fomentation and lid hygiene care were taken seriously. After 7 days, she presented with corneal perforation with iris prolapsed [Figure 7]. Her vision dropped to hand movement close to face with the perception of ray accurate. The bandage contact lens was applied and referred to higher center for corneal grafting. She underwent tectonic corneal grafting [Figure 8] and after 2 months of follow-up, she had a vision of 6/24 unaided. She was advised regular follow-up as recurrences are very common.
| Discussion|| |
Rosacea is a chronic inflammatory skin disorder with yet unclear pathogenesis. The diagnosis of rosacea is usually a clinical one. Flushing, centrofacial erythema and papules are most commonly observed. In addition, ocular rosacea may be easily missed as 20% develop ocular manifestations before any skin lesions. Fifty-three percent of patients present with preceding skin findings and 27% present with both simultaneously. The most common ocular manifestations involve the eyelids. In one report, 81% of patients presented with lid margin telangiectasia, 78% with meibomian gland dysfunction, and 65% with blepharitis. Although less common, the more serious presentation involves the cornea. In one study, 33% of patients with ocular rosacea had corneal involvement. The most common presentation was punctate epithelial erosions occurring in 13.6%. Zamil and Arfaj reported that 67% of patients presenting with corneal complaints to the ophthalmology clinic had corneal neovessels and infiltrates. Matrix metalloproteinases (MMP) are proinflammatory endopeptidases that have been implicated in corneal melting and stromal loss.,
The mainstay of treatment for blepharitis is lid hygiene. In addition, tetracycline has been proven to be effective in rosacea for many decades.,, In fact, doxycycline 100 mg daily has been shown to improve ocular disease and increase the tear break-up time. It was found to decrease the concentration of MMP-8 and MMP-9 in the tear film.,, Topical antibiotics have been used to alter the flora of the ocular surface in addition to topical steroids.,,
In patients with corneal neovascularization and stromal loss, artificial tears and gel at night, topical cyclosporine, and cautious use of steroids are recommended in addition to the above-mentioned treatment modalities.,, Tissue adhesive or amniotic membrane or both should be applied over the cornea in the case of perforation or impending perforation. Penetrating keratoplasty may be necessary in many severe cases.
My case of known acne rosacea for 3 months presented with peripheral corneal infiltrates with dry eye and blepharitis which failed to respond with systemic doxycycline, Vitamin-C, topical antibiotic, topical steroid, and lubricating drops. In follow-up after 7 days, there was corneal perforation with iris prolapsed for which she had been referred to higher center for corneal grafting. Tectonic patch graft was performed and she regained visual acuity of 6/24 (unaided).
| Conclusion|| |
Early diagnosis of ocular rosacea will allow better and prompt treatment, prevent devastating complications that might cause severe visual loss, shorten the length of therapy, and lessen the number of procedures. Suspicion of ocular rosacea shall be raised in patients with peripheral ulcerative keratitis and sterile corneal ulcer with or without any typical skin manifestation of rosacea. Trial of doxycycline and topical steroid therapy may be given in such patient and the improvement of signs and symptoms may confirm the diagnosis of ocular rosacea. Patients should monitor closely so that serious complications can be truckled easily.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]