Rosacea keratitis
 

Cornea neovascularization in rosacea keratitis Typical facial feature in acne rosacea

Acne rosacea is a common skin condition of unknown origin. Ocular involvement is common but most tend to be mild.  In the examination, the cases seen will have severe keratitis and since the ocular problems is more severe in males  most patients will be males. This is another case in which observation of the whole patient is important before starting  the slit-lamp examination otherwise the facial changes may be easily missed. The eyelids show blepharoconjunctivitis sometimes with thick meibomian secretion (chalazion may be present). There  may be scars on the tarsal conjunctiva suggesting previous recurrent chalazion. The cornea show pannus with or  without peripheral corneal thinning. There are subepithelial opacities especially inferiorly.  The face of the patient may have one or more of the following: papules and pustules facial hyperaemia dilated facial vessels (telangiectasia) in severe cases there may be rhinophyma Other signs which may be present: In severe rosacea keratitis, corneal perforation can occur. Signs of previous perforation include pigment in the  cornea stroma and distorted iris. The patient may also have tetonic graft for peripheral corneal perforation. .

Questions:

1. How would you manage the ocular problem of acne rosacea?

Answer
The problems arise from the lid and the cornea.
The lid problems include blepharitis and chronic meibomian inflammation. Lid hygiene and hot compresses are needed to keep the lids comfortable. In severe cases, oral doxycycline is useful for a period of 6 weeks but some patients may need the treatment for much longer.
The cornea problems are related to dry eyes, neovascularization and peripheral ulceration.
The dry eyes can be controlled with lid hygiene and artificial tear.
The neovascularization results from chronic corneal inflammation and low dose steroid is useful but should be used with care due to the risk of perforation.
Peripheral ulceration may result from Staphylococcal hypersensitivity and the treatment involve lid hygiene and low dose combination of steroid and antibiotic such as predsol-N.

2. A patient who is three-month pregnant develops severe blepharitis and keratitis secondary to acne rosacea.
    Would you prescribe doxycycline?

Answer
Doxycycline like tetracycline has the tendency for binding to growing structures that require calcification (chiefly teeth and bones). These can result in unsightly staining of the teeth, dental hypoplasia and bone maldevelopment. Therefore, it should be avoided in pregnant women and young children. It is also contraindicated in breast feeding women as the drug is secreted in breast milk.

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