Treatment of ocular rosacea: comparative study of topical cyclosporine and oral doxycycline

Rosacea in Older Adults and Pharmacologic Treatments

Rosacea is a chronic inflammatory skin condition that is often more severe in older patients. The main clinical features are erythema, telangiectasia, and inflammatory lesions of the face. The pathogenesis of this condition is not fully understood but certainly multifaceted. Immune and inflammatory dysregulation, genetics, neurogenic dysregulation, microbiome dysbiosis, and systemic disease have all been implicated in rosacea pathogenesis. As we better understand the various pathways that lead to rosacea, we acknowledge that the different symptoms may have unique underlying triggers and mechanisms. Aging also impacts rosacea diagnosis and treatment. Older adults have more severe rosacea symptoms while also having more sensitive and fragile skin than younger patients; therefore, rosacea treatments for older patients require a balance between delivering adequate potency while also minimizing skin irritation and other adverse effects. Until recently, rosacea diagnoses were based on concrete subtypes that did not necessarily capture each patient's manifestation of rosacea. There is now an emphasis on more personalized phenotype-based diagnoses and treatments, which allows for more emphasis on treating individual symptoms and accounting for the unique characteristics of older patients. Centrofacial erythema is best treated with brimonidine and oxymetazoline, while phymatous change and telangiectasia are best treated with surgery and laser ablation. Treatment for rosacea papules and pustules ranges from topicals, such as azelaic acid, ivermectin, metronidazole, minocycline, and encapsulated benzoyl peroxide, to systemics, such as doxycycline and isotretinoin. It is important to understand these treatments in relation to adverse effects and drug interactions that may specifically arise in older populations to provide optimal care. As we advance in understanding rosacea's pathogenesis and adopt personalized phenotype-based approaches, optimizing care for older patients becomes crucial. Continued research into novel treatments is essential to address their unique needs.

Rosacea: Pathogenesis and Therapeutic Correlates

Rosacea is a chronic inflammatory condition of which there is no cure. The pathogenesis of rosacea is likely multifactorial, involving genetic and environmental contributions. Current understanding suggests that pro-inflammatory pathways involving cathelicidins and inflammasome complexes are central to rosacea pathogenesis. Common rosacea triggers modulate these pathways in a complex manner, which may contribute to the varying severity and clinical presentations of rosacea. Established and emerging rosacea treatments may owe their efficacy to their ability to target different players in these pro-inflammatory pathways. Improving our molecular understanding of rosacea will guide the development of new therapies and the use of combination therapies.

A Review of the Diagnostic and Therapeutic Gaps in Rosacea Management: Consensus Opinion

Rosacea is a common, chronic inflammatory disease characterized by both fluctuating and fixed heterogeneous signs such as facial erythema, papules/pustules, telangiectasia, acute vasodilation (flushing), and phymatous changes, and symptoms such as cutaneous stinging and burning. The shift to a phenotype-based approach to rosacea management has improved the consistency of recommendations across recent published guidelines. Consistent and thorough guidance for the classification, diagnosis, and management of the disease is difficult, as the mechanisms underlying the development of rosacea are still not completely understood nor universally accepted. Here, we provide a critical review of current published guidance, and gaps in the knowledge and management of rosacea. We present the recently approved microencapsulated benzoyl peroxide as an effective topical treatment option for papulopustular rosacea. Benzoyl peroxide (BPO) has been used in acne management for many years; however, many clinicians perceive treatment of rosacea with any BPO formulation to be counterintuitive because of concerns of potential skin irritation, while the lack of an accepted mechanism of action on rosacea pathophysiology means that others may be hesitant to use BPO as a treatment. Minocycline foam 1.5% is also an option for the treatment of inflammatory lesions in rosacea, with a decreased risk of systemic adverse events compared with oral minocycline.

Rosacea: Practical Guidance and Challenges for Clinical Management

Rosacea is a common chronic dermatosis. Clinically, rosacea can present with flushing, erythema, papules, pustules, telangiectasias, phymatous changes, pruritus, burning, and stinging. In 2017, the National Rosacea Society Expert Committee recommended a phenotype-based classification for therapy. In this review, we identify monotherapies and multimodal treatment approaches for the clinical management of rosacea including topical, systemic, laser and light, alternative, and combination therapies.

[Rosacea-the updated S2k guideline]

Rosacea is a common chronic inflammatory dermatosis of the face, clinically characterized by erythema, telangiectasia, papules, pustules, and rhinophyma. In January 2022, the updated guideline on rosacea was published. Groundbreaking innovations include the new clinical classification according to phenotypes, extended diagnostic and therapeutic recommendations for ocular rosacea and implications of the gut microbiome on rosacea. Furthermore, the guideline encompasses a new chapter on the psychosocial aspects of rosacea and detailed recommendations for approved and off-label therapies.

Preferred practice patterns and review on rosacea

Rosacea is a chronic, inflammatory facial dermatosis commonly found in fair skin tone population. Recent studies have shown the increasing prevalence in the dark skin tone population as well. Ocular involvement is very common and can occur without cutaneous features. Common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring, and rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. The management ranges from local therapy to systemic treatment, depending on the severity of the disease. There is a positive association between demodicosis and rosacea; however, causality is always argued. In this review, we describe the epidemiology, clinical features, and treatment of rosacea and ocular rosacea.

Common ocular findings in patients with acne rosacea

PURPOSE

To evaluate ocular surface manifestations in patients with acne rosecea (AR) and to find out main features indicating a propensity toward an association with disease diagnosis.

METHODS

Right eyes of consecutive 76 AR patients and 113 age-gender matched healthy subjects were enrolled. Ophthalmologic examinations including tear break-up time (t-BUT) and Schirmer-2 tests to analyze tear film insufficiency, optical coherence tomography (OCT)-assisted infrared meibography to analyze meibomian gland drop-out, and Ocular Surface Disease Index (OSDI) questionnaire were performed in all participants.

RESULTS

No statistically differences were found in visual acuity, intraocular pressure, central corneal thickness, and axial length assessments between the study and control eyes. Study eyes had more foreign body sensation, itching, dryness, hyperemia, conjunctival telangiectasia, and meibomitis (p ≤ 0.005, for all). Significantly higher t-BUT and Schirmer-2 tests; lower-eyelid and total OCT meibography; and OSDI scores were found in AR patients (p < 0.05, for all). Among all, only conjunctival telangiectasia (p = 0.001; OR:0.070, 95% CI:0.015-0.330) was found to be major independent predictor for AR diagnosis.

CONCLUSION

Detailed slit-lamp examination to detect any conjunctival telangiectasia seems to be crucial in recalcitrant dry eye cases, not to miss underlying AR. Especially, lower-eyelid OCT meibography score may be sensitively used for disease staging.

Clinical manifestations and long-term outcomes in three ocular rosacea cases treated at a highly specialized hospital in southeast México

Rosacea is a chronic skin disorder that has been associated with unspecific etiological factors and diverse systemic manifestations. Cutaneous rosacea usually evolves to ocular rosacea in 6 to 72% of patients. In the absence of specific criteria to characterize this pathology, ocular rosacea can mean a diagnostic challenge. To strengthen early diagnostic suspicion, we present three cases of patients with different clinical evolution who had in common diagnostic delay resulting in severe manifestations and extensive ocular damage.

Topical cyclosporine A therapy for dry eye syndrome

BACKGROUND

Topical cyclosporine A (also known as ciclosporin A) (CsA) is an anti-inflammatory that has been widely used to treat inflammatory ocular surface diseases. Two CsA eyedrops have been approved by US Food and Drug Administration for managing dry eye: Restasis (CsA 0.05%, Allergan Inc, Irvine, CA, USA), approved in 2002, and Cequa (CsA 0.09%, Sun Pharma, Cranbury, NJ, USA), approved in 2018. Numerous clinical trials have been performed to assess the effectiveness and safety of CsA for dry eye; however, there is no universal consensus with regard to its effect.

OBJECTIVES

To assess the effectiveness and safety of topical CsA in the treatment of dry eye.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 16 February 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people with dry eye regardless of age, sex, severity, etiology, or classification of dry eye. We included RCTs in which different concentrations of topical CsA were compared with one another or with artificial tears, placebo, or vehicle. We also included RCTs in which CsA in combination with artificial tears was compared to artificial tears alone.

DATA COLLECTION AND ANALYSIS

We followed the standard Cochrane methodology and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 30 RCTs (4009 participants) with follow-up periods ranging from 6 weeks to 12 months. We studied dry eye of various severity and underlying causes. The interventions investigated also varied across RCTs: CsA versus artificial tears; CsA with artificial tears versus artificial tears alone; and in some studies, more than one concentration of CsA. Artificial tears were used as adjunctive to study medication in all but five trials. Almost all trials had deficiencies in the reporting of results (e.g. reporting P values or direction only), precluding the calculation of between-group estimates of effect or meta-analysis.Eighteen trials compared topical CsA 0.05% plus artificial tears versus vehicle plus artificial tears or artificial tears alone. One trial reported subjective symptoms of dry eye at 6 months and the results were in favor of CsA (mean difference (MD) -4.80, 95% confidence interval (CI) -6.41 to -3.19; low-certainty evidence). Two trials reported MD in ocular surface dye staining at 6 months, but the results were inconsistent in these two trials (MD -0.35, 95% CI -0.69 to -0.01 in one and MD 0.58, 95% CI 0.06 to 1.10 in the other; low-certainty evidence). Four trials reported MD in Schirmer test scores at 6 months and the estimates ranged from -4.05 (95% CI -6.67 to -1.73) to 3.26 (95% CI -1.52 to 5.00) (low-certainty evidence). Three trials reported risk ratio (RR) of improved Schirmer test scores at 6 months; estimates ranged from 0.98 (95% CI 0.83 to 1.17) to 3.50 (95% CI 2.09 to 5.85) (low-certainty evidence). Four trials reported MD in tear film stability measured by tear break-up time at 6 months and the estimates ranged from -1.98 (95% CI -3.59 to -0.37) to 1.90 (95% CI 1.44 to 2.36) (low-certainty evidence). Three trials reported RR of improved tear break-up time at 6 months and the estimates ranged from 0.90 (95% CI 0.77 to 1.04) to 4.00 (95% CI 2.25 to 7.12) (low-certainty evidence). Three trials reported frequency of artificial tear usage at 6 months without providing any estimates of effect; the direction of effect seem to be in favor of CsA (low-certainty evidence). Because of incomplete reporting of the results data or considerable statistical heterogeneity, we were only able to perform a meta-analysis on mean conjunctival goblet cell density. Mean conjunctival goblet cell density in the CsA treated group may be greater than that in the control group at the end of follow-up at four and 12 months (MD 22.5 cells per unit, 95% CI 16.3 to 28.8; low-certainty evidence). All but two trials reported adverse events that included burning and stinging. Participants treated with CsA may be more likely to have treatment-related adverse events than those who treated with vehicle (RR 1.33, 95% CI 1.00 to 1.78; low-certainty evidence).Other comparisons evaluated were CsA 0.05% plus artificial tears versus higher concentrations of CsA plus artificial tears (4 trials); CsA 0.05% versus placebo or vehicle (4 trials); CsA 0.1% plus artificial tears versus placebo or vehicle plus artificial tears (2 trials);CsA 0.1% cationic emulsion plus artificial tears versus vehicle plus artificial tears (2 trials); CsA 1% plus artificial tears versus placebo plus artificial tears (3 trials); and CsA 2% plus artificial tears versus placebo plus artificial tears (3 trials). Almost all of these trials reported P value or direction of effect only (mostly in favor of CsA), precluding calculation of between-group effect estimates or meta-analyses.

AUTHORS' CONCLUSIONS

Despite the widespread use of topical CsA to treat dry eye, we found that evidence on the effect of CsA on ocular discomfort and ocular surface and tear film parameters such as corneal fluorescein staining, Schirmer's test, and TBUT is inconsistent and sometimes may not be different from vehicle or artificial tears for the time periods reported in the trials. There may be an increase in non-serious, treatment-related adverse effects (particularly burning) in the CsA group. Topical CsA may increase the number of conjunctival goblet cells. However, current evidence does not support that improvements in conjunctival mucus production (through increased conjunctival goblet cells) translate to improved symptoms or ocular surface and tear film parameters. All published trials were short term and did not assess whether CsA has longer-term disease-modifying effects. Well-planned, long-term, large clinical trials are needed to better assess CsA on long-term dry eye-modifying effects. A core outcome set, which ideally includes both biomarkers and patient-reported outcomes in the field of dry eye, is needed.

Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments

BACKGROUND

Rosacea is a common chronic facial dermatosis. Classification of rosacea has evolved from subtyping to phenotyping.

OBJECTIVES

To update our systematic review on interventions for rosacea.

METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index and ongoing trials registers (March 2018) for randomized controlled trials. Study selection, data extraction, risk-of-bias assessment and analyses were carried out independently by two authors. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess certainty of evidence.

RESULTS

We included 152 studies (46 were new), comprising 20 944 participants. Topical interventions included brimonidine, oxymetazoline, metronidazole, azelaic acid, ivermectin and other topical treatments. Systemic interventions included oral antibiotics, combinations with topical treatments or other systemic treatments. Several studies evaluated laser or light-based treatment. We present the most current evidence for rosacea management based on a phenotype-led approach.

CONCLUSIONS

For reducing temporarily persistent erythema there was high-certainty evidence for topical brimonidine and moderate certainty for topical oxymetazoline; for erythema and mainly telangiectasia there was low-to-moderate-certainty evidence for laser and intense pulsed light therapy. For reducing papules/pustules there was high-certainty evidence for topical azelaic acid and topical ivermectin; moderate-to-high-certainty evidence for doxycycline 40 mg modified release (MR) and isotretinoin; and moderate-certainty evidence for topical metronidazole, and topical minocycline and oral minocycline being equally effective as doxycycline 40 mg MR. There was low-certainty evidence for tetracycline and low-dose minocycline. For ocular rosacea, there was moderate-certainty evidence that oral omega-3 fatty acids were effective and low-certainty evidence for ciclosporin ophthalmic emulsion and doxycycline.

Effect of topical 0.05% cyclosporine A on the tear protein lacritin in a rat model of dry eye

AIM

To observe the effect of topical 0.05% cyclosporine A (CsA) on the ocular surface and tear protein lacritin in a botulinum B-induced dry eye rat model.

METHODS

A total of 36 female SD rats were randomly divided into 3 groups, botulinum B was injected into the right lacrimal gland of all rats. Group A and group B were treated with 0.05% CsA and 0.1% sodium hyaluronate, respectively, 3 times daily. The control group was not treated. Basal tear flow, corneal epithelial defects, and lacritin levels were measured.

RESULTS

Tear secretion in all rats was reduced on day 3 and was even lower on day 7 postoperation (P<0.05). Tear secretion in group A increased by day 14 and was at the preoperative level on day 42. Tear secretion in group B and control rats was lower on days 14 and 42 compared with preoperative level (P<0.05). Corneal fluorescein staining in group A was higher on day 3, peaked on day 7, and then decreased gradually from day 7 until day 14, returning to normal by day 42 post-procedure. However, in group B, corneal fluorescein staining had improved, but was not fully recovered by day 42. Corneal fluorescein staining was more intense than before the operation and then in the control group at all time points. Tear protein lacritin levels reached the lowest levels on day 7 in all groups. In group A, tear protein lacritin levels began to increase on day 14 and were normal on day 42. In group B, tear protein lacritin levels began to increase on day 14, but had not completely recovered on day 42. In the control group, tear protein lacritin levels remained low post-procedure.

CONCLUSION

CsA 0.05% prompts tear protein lacritin expression in a rat model of dry eye and improves the signs and symptoms of dry eye disease.

Dry Eye Disease: Consideration for Women's Health

Dry eye disease (DED) is a multifactorial disorder of the ocular surface and tear homeostasis that can result in discomfort, pain, and visual disturbance. Untreated, DED can become chronic, progressive, and significantly affect an individual's quality of life. Women are disproportionately affected by DED, are diagnosed at a younger age, and experience more severe symptoms compared with men. DED is associated with a wide range of comorbid conditions; there is a strong association between DED and autoimmune disorders, especially those that affect women at many times the rate of men. Treatment response questionnaires indicate women respond better to a wellness model of treatment for DED than men. Furthermore, women's health care-seeking behaviors provide opportunities for general practitioners, specialists, and women's health centers to help identify women with DED or at risk for DED for referral to an eye care specialist. This review of the prevalence of DED in women, and gender and sex-specific aspects of DED, highlight a significant opportunity for action. Earlier diagnosis and treatment of this common but burdensome condition could significantly improve a woman's quality of life.

[Ophthalmic Rosacea: etiopathogenesis and modern treatment methods]

Rosacea is a multifactorial chronic inflammatory disease with various clinical manifestations. Primarily it is seen as a dermatological condition, but it's not uncommon for it to develop ophthalmological implications affecting eyelids, cornea and conjunctiva. The article describes main aspects of its etiopathogenesis, variations in its clinical course and treatment approaches. There is currently no universal treatment strategy for the disease due to its varying clinical manifestation, particularly of its ophthalmological form, differing severity of the pathological process, lack of knowledge about its etiology and pathogenesis. Leading role in its pathological process belongs to disturbance of regulatory mechanisms of the vascular, immune and nervous systems. Additionally, higher levels of metalloproteinases and vascular endothelial growth factor (VEGF) can be observed. Possible influence of a range of micro-organisms also hasn't been excluded. Basic therapy involves both systemic and topical drugs. The first include tetracycline antibiotics. A new direction in Rosacea treatment that aims at structural and functional restoration of vascular endothelium, improvement of microcirculation and recovery of rheological properties of blood is angioprotector therapy, in particular with Calcium Dobesilate (Doxi-Hem). Aside from systemic drugs, the ophthalmological forms of Rosacea are treated topically with anti-inflammatory preparations, immunosuppressants and artificial tears that are chosen depending on the symptoms' severity. In cases with heavy corneal damage, various types of keratoplasty can be performed. Collaboration between ophthalmology and dermatology specialists is necessary in order to choose adequate strategy for Rosacea treatment.

Clinical efficacy of combined topical 0.05% cyclosporine A and 0.1% sodium hyaluronate in the dry eyes with meibomian gland dysfunction

AIM

To investigate the efficacy of combined topical 0.05% cyclosporine A (CsA; Restasis^®, Allergan pharmaceuticals, USA) and 0.1% sodium hyaluronate treatment in dry eyes with meibomian gland dysfunction (MGD).

METHODS

In a retrospective analysis, 53 patients (106 eyes) with MGD were enrolled and performed lid warm massage for 10min daily and be instilled preservative free sodium hyaluronate 0.1% eye drops 4 times daily. Patients were divided into subjects treated with topical 0.05% CsA and preservative free sodium hyaluronate vehicle (experimental group, n=74 eyes) and subjects treated with the preservative free sodium hyaluronate vehicle (control group, n=32 eyes). They were evaluated at baseline and 1, 2, and 3mo for subjective symptoms and objective signs including tear film break-up time (tBUT), Schirmer test, corneal staining (CS) score, lid margin telangiectasia (LMT), meibomian gland secretion (MGS), and conjunctival injection (CI).

RESULTS

In the short-term treatment, the experimental group showed a statistically significant improvement in the ocular surface disease index (OSDI; P<0.001), tBUT (P=0.004), Schirmer test score (P=0.008) and LMT (P=0.021) by repeated measure ANOVA. Additionally, mean changes from baseline in OSDI (P<0.001), tBUT (P=0.001), Schirmer test score (P=0.029), CS score (P=0.047), LMT (P=0.002), CI (P=0.030) were improved better in the experimental group than in the control group at 3mo. However, there was no significant difference between the two groups in MGS (P=0.67).

CONCLUSION

In dry eyes with MGD, 0.05% CsA improves the tear film stability as well as subjective ocular discomfort, and is effective in controlling lid margin inflammation.

Patient and physician perspectives on the use of cyclosporine ophthalmic emulsion 0.05% for the management of chronic dry eye

Dry eye disease (DED) is a multifactorial disease of the ocular surface and is one of the most common reasons for patients to visit an eye care provider. Cyclosporine A (CsA) is an immune modulating drug that was approved in the US for topical use in the treatment of DED in 2003, which led to a paradigm change in our understanding and treatment of DED, turning attention to control of inflammation for treatment. This review summarizes the literature to date regarding the impact of CsA on the treatment of DED. A special focus is given to the patient and physician perspectives of CsA, including dry eye symptom improvement, medication side effects, and overall patient satisfaction. Studies evaluating CsA in DED have considerable heterogeneity making generalized conclusions about the effect of CsA difficult. However, most studies have demonstrated improvement in at least some symptoms of dry eye in CsA-treated patients. Side effects, most commonly ocular burning on administration of CsA, are common. The literature is sparse regarding long-term follow-up of patients treated with CsA, optimal duration of treatment, and identifying which patients may receive the most benefit from CsA.

Ocular Rosacea Causing Corneal Melt in an African American Patient and a Hispanic Patient

Purpose

To discuss two rare presentations of ocular rosacea in a Hispanic patient and an African American patient with unusual ocular manifestations.

Case Report

Case  1: a 43-year-old Hispanic woman presented with right eye corneal perforation. Her prior medical history was significant for rosacea only, diagnosed clinically by a dermatologist. Her eye exam showed signs of bilateral ocular rosacea. An emergent full thickness tectonic corneal patch graft was done. The patient's bilateral eye symptoms improved one month after initiating rosacea treatment. Case  2: a 51-year-old African American man with long standing history of untreated rosacea presented with bilateral peripheral corneal thinning with neovascularization that led to right eye corneal perforation. Glue and bandage contact lens were applied. The patient did well 4 weeks after starting antibacterial, oral steroids, and rosacea treatment.

Discussion

Ocular rosacea can present in Hispanic and African American patients with severe manifestations such as corneal perforation.

Rosacea Management

BACKGROUND

Rosacea is a chronic inflammatory skin condition associated with four distinct subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular.

PURPOSE

To review the different kinds of management for all subtypes.

METHODS

We divided rosacea management into three main categories: patient education, skin care, and pharmacological/procedural interventions.

RESULTS

Flushing is better prevented rather than treated, by avoiding specific triggers, decreasing transepidermal water loss by moisturizers, and blocking ultraviolet light. Nonselective β-blockers and α₂-adrenergic agonists decrease erythema and flushing. The topical α-adrenergic receptor agonist brimonidine tartrate 0.5% reduces persistent facial erythema. Intradermal botulinum toxin injection is almost safe and effective for the erythema and flushing. Flashlamp-pumped dye, potassium-titanyl-phosphate and pulsed-dye laser, and intense pulsed light are used for telangiectasias. Metronidazole 1% and azelaic acid 15% cream reduce the severity of erythema. Both systemic and topical remedies treat papulopustules. Systemic remedies include metronidazole, doxycycline, minocycline, clarithromycin and isotretinoin, while topical remedies are based on metronidazole 0.75%, azelaic acid 15 or 20%, sodium sulfacetamide, ivermectin 1%, permethrin 5%, and retinoid. Ocular involvement can be treated with oral or topical antibacterial. Rhinophyma can be corrected by dermatosurgical procedures, decortication, and various types of lasers.

CONCLUSION

There are many options for rosacea management. Patients may have multiple subtypes, and each phase has its own treatment.

Therapeutical Management for Ocular Rosacea

Purpose

The purpose of this study is to describe a case of ocular rosacea with a very complex evolution. Rosacea is a chronic dermatological disease that may affect the ocular structures up to 6-72% of all cases. This form is often misdiagnosed, which may lead to long inflammatory processes with important visual consequences for affected patients. Therefore, an early diagnosis and an adequate treatment are important.

Methods

We report the case of a 43-year-old patient who had several relapses of what seemed an episode of acute bacterial conjunctivitis. Two weeks later, he developed a corneal ulcer with a torpid evolution including abundant intrastromal infiltrators and calcium deposits. He was diagnosed with ocular rosacea and treated with systemic doxycycline and topical protopic.

Results

A coating with amniotic membrane was placed in order to heal the ulcer, but a deep anterior lamellar keratoplasty to restore the patient's vision because of the corneal transparency loss was necessary.

Conclusions

Ocular rosacea includes multiple ophthalmic manifestations ranging from inflammation of the eyelid margin and blepharitis to serious corneal affectations. A delayed diagnosis can result in chronic inflammatory conditions including keratinization and loss of corneal transparency, which lead to important visual sequelae for affected patients.