Topical ciclosporin in the treatment of ocular surface disorders

Mounting evidence suggests that inflammation is the key factor in the pathogenesis of various ocular surface diseases, with a complex interplay of genetic, environmental, and psychosocial factors. Management of these conditions is often challenging. Topical corticosteroids, with their associated side effects, are the mainstay of current treatments for patients with vision threatening disease. Ciclosporin A is an immunomodulator that specifically inhibits T lymphocyte proliferation. Recently, a topical ciclosporin preparation was approved by the US Food and Drug Administration and became available for use in ophthalmology. Given the increasing use of ciclosporin eye drops, the goal of this article is to provide the reader with an overview of the well established uses of ciclosporin and to help refine the questions that should be addressed by future investigations.

Immune defense at the ocular surface

The ocular surface is constantly exposed to a wide array of microorganisms. The ability of the outer ocular system to recognize pathogens as foreign and eliminate them is critical to retain corneal transparency, hence preservation of sight. Therefore, a combination of mechanical, anatomical, and immunological defense mechanisms has evolved to protect the outer eye. These host defense mechanisms are classified as either a native, nonspecific defense or a specifically acquired immunological defense requiring previous exposure to an antigen and the development of specific immunity. Sight-threatening immunopathology with autologous cell damage also can take place after these reactions. This article discusses the innate and acquired corneal elements of the immune defense at the ocular surface. The relative roles of the various factors contributing to prevention of eye infection remain to be fully defined.

Clinical and ultrastructural features of a novel hereditary anterior segment dysgenesis

OBJECTIVE

To describe the clinical, histopathologic, and hereditary features of a novel familial anterior segment dysgenesis.

DESIGN

Prospective, observational case series and interventional case report.

PARTICIPANTS

Ten individuals from three generations of a single family with iris and corneal abnormalities associated with congenital cataracts.

MAIN OUTCOME MEASURES

An ophthalmic evaluation including slit-lamp examination, corneal topography, pachymetry, and specular biomicroscopy of all family members, and histopathologic and ultrastructural evaluation of one excised corneal button.

RESULTS

The proband was an 81-year-old man with bilateral aphakia and diffuse corneal haze, and thinning associated with corneal guttae. His pupils were small, mildly eccentric, and difficult to dilate. Pachymeter readings were 335 microm (right eye) and 330 microm (left eye). Topography confirmed advanced steepening of both corneas. Light microscopic and transmission electron microscopic examinations of the corneal button revealed an attenuated endothelium with prominent intracellular random aggregates of small-diameter filaments staining positively for cytokeratin. Descemet's membrane was thickened and had marked posterior nodularity. Various-sized polymorphic vacuoles containing layered electron-dense material were present within and between collagen lamellae and within keratocytes throughout the stroma and Bowman's membrane. Secondary bullous changes of the epithelium with thickening of the basement membrane were also observed. The family pedigree demonstrated an autosomal dominant inheritance pattern.

CONCLUSIONS

This constellation of autosomal dominantly inherited corneal endothelial and stromal disorder, with congenital cataracts and iris abnormalities, represents a novel anterior segment disorder. Its etiology may involve an abnormal migration of the secondary mesenchyme.

Spontaneous corneal perforation in a patient with unusual unilateral pellucid marginal degeneration

A 56-year-old man presented with acute loss of vision and tearing in his left eye. Slitlamp examination demonstrated peripheral corneal edema extending between the 2 and 6 o'clock positions as well as a perforation located inferiorly. The right eye was unremarkable. An emergent crescentic lamellar keratoplasty was performed. The patch graft remained clear during the 30-month follow-up, and visual acuity improved significantly. No changes occurred in the right eye. This case represents an unusual, unilateral corneal ectatic disorder, most likely pellucid marginal degeneration.

Long-term immunosuppressive treatment of serpiginous choroiditis

OBJECTIVE

To determine the efficacy of immunosuppressive treatment in serpiginous choroiditis.

DESIGN

The clinical courses were reviewed of six consecutive patients (12 eyes) with vision-threatening, steroid-dependent/resistant serpiginous choroiditis treated with a combination of immunosuppressive agents including azathioprine, cyclosporine, and cyclophosphamide. All patients underwent treatment for at least 12 months.

RESULTS

The follow-up period ranged from 17 to 105 months (mean 57, median 43). All patients were able to taper oral steroids. Five patients discontinued all immunosuppressive medications after a treatment period of 12 to 69 months (mean 39 months). Immunosuppressive treatment was continued in one patient at a "low" maintenance dose. Ten eyes had improved visual acuities, while vision remained impaired in two due to macular scars. Recurrence was noted in two patients when an attempt was made to decrease the dose of immunosuppressive medication. Two patients experienced side effects which were reversed by decreasing the dose of the medications.

CONCLUSION

Long-term immunosuppressive treatment appears to prolong remission and preserve vision in patients with serpiginous choroiditis.

Induction of experimental autoimmune keratitis by adoptive transfer of human corneal antigen-specific T-cell line

PURPOSE

To establish a permanent human corneal antigen (HuCOAg)-specific T-cell line and to determine whether line cells are capable of inducing inflammatory keratitis by adoptive transfer.

METHODS

Lymphoid cells harvested from HuCOAg-immunized Lewis rats were expanded to a permanent T-cell line by repetitive cycles of restimulation with HuCOAg and irradiated antigen-presenting cells and propagation in interleukin 2-containing medium. The phenotype and epitope specificity of the line cells were determined. Adoptive transfer was performed after seven cycles by intraperitoneal injection of activated T cells into irradiated recipient rats.

RESULTS

A panel of 11 overlapping synthetic HuCOAg peptides to identify T-cell epitopes recognized by the line cells was used. The cells responded selectively to a synthetic peptide containing an immunodominant epitope of HuCOAg (peptides 69-83). Line cells bore the surface phenotype of the T-helper/inducer marker (W 3/25(+) or CD4(+)). Intraperitoneal inoculation of naive rats with 5 x 10(7) activated line cells led to maximal clinical signs of stromal keratitis 7 to 9 days after transfer, characterized by corneal haze, conjunctival and episcleral injection, corneal infiltrates, and neovascularization. Histopathologic examination of the tissues revealed numerous lymphocytes and macrophages and some polymorphonuclear leukocytes along with neovascularization. The pathologic lesions were confined to the peripheral corneal stroma. Immunohistochemical studies demonstrated that the overwhelming majority of the inflammatory cells were CD4(+) T lymphocytes and macrophages; an upregulation of major histocompatibility complex class II antigen expression was also noted.

CONCLUSIONS

A long-term, rat T-cell line of CD4(+) phenotype specific for HuCOAg that can induce autoimmune keratitis by adoptive transfer of the line cells to naive syngeneic recipients is described. With the development of this cell line, the mechanisms by which T cells exert their immunopathologic effects in experimental autoimmune keratitis models can be studied.

Peripheral ulcerative keratitis after clear corneal cataract extraction(1)

A previously healthy 80-year-old man had uneventful clear corneal cataract extraction. An extensive peripheral corneal infiltrate with overlying epithelial defect at the incision site was noted at the regular follow-up visit 1 week after surgery. Corneal cultures showed no evidence of infectious keratitis. A systemic evaluation uncovered early-stage, active rheumatoid arthritis. This case illustrates that peripheral ulcerative keratitis may occur with a small clear corneal incision and may be the presenting sign of a previously undiagnosed rheumatoid disease.

Choroidopathy of systemic lupus erythematosus

PURPOSE

To describe the ocular and systemic manifestations associated with systemic lupus erythematosus (SLE) choroidopathy.

METHODS

Three new cases of choroidopathy in patients with active SLE were described. Twenty-five published cases of lupus choroidopathy were summarized.

RESULTS

There have been 28 cases of lupus choroidopathy (47 involved eyes) that have been reported in the English literature since 1968, including the three current cases. Only two of the patients were male. The choroidopathy was bilateral in 19 patients (68%). All 28 patients (100%) had active systemic vascular disease at the onset of their choroidopathy; 18 (64%) had nephropathy and 10 (36%) had central nervous system (CNS) lupus vasculitis. All but one of the patients had a known diagnosis of SLE at the onset of choroidopathy. 30 of the 47 involved eyes had presenting visual acuity of 20/40 or better; 14 eyes showed improvement in visual acuity with therapy. 23 patients (82%) had resolution of their choroidopathy when their systemic disease was brought under control. Despite treatment, 4 of the 28 patients (14%) died from complications of SLE.

CONCLUSIONS

Although less known than retinopathy, lupus choroidopathy may be more common than generally appreciated. It usually serves as a sensitive indicator of lupus activity. The presence of SLE choroidopathy is generally indicative of coexistent (although sometimes occult) nephropathy, CNS vasculitis, and other SLE visceral lesions. Immunomodulation of the systemic disease can lead to improvement and resolution of the systemic vasculitis as well as the choroidopathy.

Herpes zoster sine herpete presenting with hyphema

PURPOSE

To report a case of herpes zoster sine herpete presenting with hyphema.

METHODS

A 69-year-old man was referred for traumatic hyphema and corneal edema in his left eye after a sandblast exposure three weeks previously. Slit-lamp examination demonstrated hyphema, anterior chamber inflammation, mid-dilated pupil, impaired corneal sensation, and high intraocular pressure, without any facial skin lesions. Iris fluorescein angiography revealed tortuosity and extensive occlusion of iris vessels. The patient was treated with oral acyclovir and intensive topical steroids with a presumed diagnosis of severe herpes zoster uveitis.

RESULTS

Clinical findings improved dramatically within several days. Typical sectorial iris atrophy with pupillary sphincter dysfunction and complete loss of corneal sensation developed after the resolution of intraocular inflammation.

CONCLUSION

Herpes zoster should be considered in patients with uveitis and hyphema even in the absence of typical skin rash.

A randomized trial of low-dose, topical mitomycin-C in the treatment of severe vernal keratoconjunctivitis

OBJECTIVE

To evaluate the efficacy and safety of low-dose, topical mitomycin-C in patients with severe vernal keratoconjunctivitis.

DESIGN

Placebo-controlled, double-masked, randomized clinical trial.

PARTICIPANTS

Twenty-six patients with vernal keratoconjunctivitis refractory to combination of steroid and mast-cell stabilizer treatment.

INTERVENTION

Patients were randomly assigned (2:1) to treatment with topical 0.01% mitomycin-C eye drops (n = 17) or placebo (n = 9) three times daily for 2 weeks.

MAIN OUTCOME MEASURES

Symptoms (itching, tearing, photophobia, ropy mucous discharge, foreign body sensation) and signs (conjunctival hyperemia, epithelial punctate keratitis, Trantas' dots, limbal edema, and palpebral conjunctival giant papillae) of vernal keratoconjunctivitis recorded on the day of enrollment and at the end of the treatment period.

RESULTS

There was a statistically significant decrease in ropy mucous discharge, photophobia, conjunctival hyperemia, and limbal edema in the mitomycin-C treated group compared with the placebo group at the end of the 2-week treatment period. In addition, none of the 17 treated patients, but all 9 of the placebo patients, required medication during the 4-week posttreatment follow-up period. No adverse effects of treatment with mitomycin-C were observed.

CONCLUSIONS

Short-term, low-dose, topical mitomycin-C may be considered in the acute exacerbation periods of patients with severe vernal keratoconjunctivitis refractory to conventional treatment.

Topical cyclosporin stimulates neovascularization in resolving sterile rheumatoid central corneal ulcers

OBJECTIVE

To report the successful use of topical cyclosporin for treatment of central sterile corneal ulcers associated with rheumatoid disease.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS/INTERVENTION

Five patients (7 eyes) with collagen vascular disorders presented with central, sterile corneal ulcers. An extensive medical evaluation did not reveal active underlying rheumatoid disease in any patient. Inadequate clinical response with use of topical steroids and lubricants led to corneal perforations requiring multiple tectonic procedures. Systemic immunosuppressive therapy either could not be initiated owing to a systemic contraindication or was discontinued owing to intolerance and side effects. The patients were ultimately treated with topical cyclosporin.

RESULTS

Six of the 7 eyes responded favorably. An intense limbal vascularization began within 48 hours of treatment. The neovascularization progressed centrally with the simultaneous arresting of epithelial and stromal ulceration. Over a 2-week period, re-epithelization occurred with vascularization proceeding throughout the cornea. After several months, the corneal vessels attenuated, and all signs of inflammation subsided. Intrastromal bleeding with corneal blood staining occurred in 1 patient; this resolved over several months. No recurrences of corneal ulceration occurred in a mean follow-up period of 28 months (range, 7 to 60 months). None of the 5 patients have had a reactivation of their rheumatoid disease in the follow-up period.

CONCLUSION

The clinical response in these patients contrasts with previous animal studies demonstrating an anti-angiogenic property of cyclosporin. We report that an immediate intense neovascularization is the first sign of a favorable clinical response. Treatment with topical cyclosporin alone may be considered in patients with sterile corneal ulcers associated with rheumatoid disease in the absence of systemic activation.

Bilateral consecutive central corneal perforations associated with hypogammaglobulinemia

OBJECTIVE

To describe the presentation and the clinical course of a patient with consecutive central sterile corneal perforations associated with common variable immunodeficiency.

DESIGN

Case report.

METHODS

Multiple corneal cultures and scrapings were performed in an effort to identify an infectious cause and all were negative. Corneal biopsy did not demonstrate any evidence of micro-organisms. An extended investigation failed to uncover a collagen vascular cause or atopy.

RESULTS

Progressive sterile stromal thinning with intact epithelium in the left eye proceeded to perforation despite topical treatment, and cyanoacrylate gluing was performed. However, a secondary Haemophilus influenza endophthalmitis developed, and the eye was eventually lost. The fellow eye proceeded along the same clinical course with sterile stromal thinning. A lamellar patch graft was performed when the central ulceration progressed to a descemetocele. The eye remained quiet with 20/25 vision for 2 years, until the patient died from complications of a liver transplant.

CONCLUSIONS

Devastating central sterile corneal thinning leading to perforation may occur in patients with hypogammaglobulinemia.

Elevated vitreous interleukin-10 level is not diagnostic of intraocular-central nervous system lymphoma

OBJECTIVE

Diagnosis of intraocular-central nervous system (CNS) lymphoma is commonly made by identifying malignant lymphocytes in the vitreous. However, such cells are in the minority in the vitreous cellular infiltrate (most are reactive lymphocytes), and therefore lack of cytologic support from biopsied vitreous samples in patients suspected of having intraocular-CNS lymphoma may occur. Recent data suggest that interleukin-10 (IL-10) levels are elevated in the serum and vitreous of patients with non-Hodgkin's lymphoma, whereas IL-12 and IL-6 levels are elevated in patients with uveitis of non-neoplastic etiology. The authors evaluated the usefulness of measuring vitreous levels of IL-6, -10, and -12 in the diagnosis of intraocular-CNS lymphoma.

DESIGN

Prospective case series.

PARTICIPANTS

Seventeen patients with intraocular inflammation who underwent a diagnostic or therapeutic vitrectomy: 4 patients with intraocular-CNS lymphoma and 13 patients with uveitis unrelated to a neoplasm.

INTERVENTION

Eighteen vitreous specimens were obtained prospectively. Concentrations of IL-6, -10, and -12 were measured by enzyme immunosorbent assay, and relative ratios of the interleukins were calculated. Cytopathologic examination and flow cytometry of vitreous cells were also performed.

MAIN OUTCOME MEASURES

The ratio of IL-10/IL-12 and IL-10/IL-6 was calculated to assess any association of intraocular-CNS lymphoma and high vitreous IL-10 relative to IL-6 and IL-12 levels.

RESULTS

The IL-10/IL-6 and IL-10/IL-12 ratio was greater than 1 in 8 of 14 vitreous specimens obtained from 13 patients with non-neoplastic uveitis. One of the four specimens from patients with cytologically proven intraocular-CNS lymphoma had vitreous IL-10/IL-6 and IL-10/IL-12 ratios of less than 1.

CONCLUSION

Although a helpful diagnostic tool, an elevated vitreous IL-10 to IL-6 or IL-12 ratio is not always associated with intraocular-CNS lymphoma.

Krill protease effects on wound healing after corneal alkali burn

PURPOSE

To study the effect of a novel protease in the development and progression of corneal ulceration secondary to alkali burning.

METHODS

By using a 4N alkali burn model of corneal ulceration in rabbits, the effects and efficacy of topical application of a novel protease (PHM-101) capable of degrading metalloproteinases was studied for 28 days of treatment and 7 days off treatment for its effect on corneal ulceration and recurrent erosion.

RESULTS

At day 28, both the protease- and placebo-treated groups had different numbers of eyes showing reepithelialization (nine (45%) of 20 and six (33%) of 18, respectively]. By day 35 the protease-treated group had significantly fewer recurrent epithelial defects [two (13%) of 15 vs. eight (61%) of 13; p = 0.02]. Similarly, at day 35 the protease-treated group showed significantly less corneal ulceration [two (13%) of 15 vs. six (46%) of 13; p = 0.02], and those ulcers were of a lesser severity (three units vs. 17.76 units). No difference was found in the degree of stromal edema or neovascularization, nor was there any difference in histopathologic characteristics of inflammatory cell infiltration and corneal scarring.

CONCLUSION

We conclude that this novel protease is efficient in reducing recurrent corneal epithelial defects and stromal ulceration after alkali burning.

Intraocular-central nervous system lymphoma: clinical features, diagnosis, and outcomes

OBJECTIVE

To analyze the clinical features, laboratory investigations, and diagnosis of intraocular-central nervous system (CNS) lymphoma in a cohort of patients who underwent diagnostic vitrectomy.

DESIGN

Retrospective case series. METHOD AND STUDY MATERIALS: Thirty-four vitreous biopsy specimens obtained from 26 patients with treatment-resistant or unusual uveitis were re-evaluated in a masked fashion. The specimens were classified into three groups: "negative," "suspicious of malignancy," and "positive" based on the cytologic features, immunomarkers, and flow cytometry. The medical records of the patients were reviewed retrospectively.

MAIN OUTCOME MEASURES

The reliability of vitreous cytology in diagnosing intraocular-CNS lymphoma and the differences in clinical features of patients with intraocular-CNS lymphoma and uveitis.

RESULTS

The two ocular pathologists concurred in their criteria for interpretation of all specimens. There was 100% concordance between the cytologic reports read independently by the two ocular pathologists over the 5-year period and the read-out done in a masked fashion at the time of the study. Ten patients were diagnosed with intraocular-CNS lymphoma based on the vitreous cytology and clinical features. The time interval between the initial presentation and vitreous biopsy was 1 week to 2 years, with 80% of the patients diagnosed within the first year. Retinal involvement in the form of lymphomatous subretinal pigment epithelial infiltrates, vasculitis, and apparent retinochoroiditis was present in six cases. Initial neuroimaging studies revealed concomitant CNS involvement in three patients, and an additional three developed CNS lymphoma following diagnosis by vitreous biopsy. Patients were treated with radiotherapy, chemotherapy, or both. Two of the four patients with a follow-up of greater than 12 months died due to CNS involvement.

CONCLUSIONS

Vitreous cytology is a sensitive, reliable, and reproducible method of diagnosing intraocular-CNS lymphoma. A high index of suspicion based on the clinical findings and course of the uveitis is critically important in decision-making for diagnostic vitrectomy. Central nervous system involvement is frequent and associated with a high mortality rate. Ophthalmology 1999;106:1805-1810

Ocular surface neoplasia masquerading as chronic blepharoconjunctivitis

PURPOSE

To present the clinical characteristics and difficulties in the diagnosis of various ocular surface malignancies mimicking features of chronic blepharoconjunctivitis and to summarize the current therapeutic approach and prognosis of patients.

METHODS

Six patients with slowly evolving signs of persistent inflammation underwent a conjunctival biopsy after a prolonged course of medical treatment. The medical records of the patients were reviewed.

RESULTS

Histopathologic examination of the biopsy specimens revealed intraepithelial squamous neoplasia (one patient), invasive squamous cell carcinoma (one patient), sebaceous carcinoma (two patients), and conjunctival lymphoma (two patients).

CONCLUSION

Although uncommon, ocular surface malignancies may involve the conjunctiva diffusely and present as chronic conjunctivitis. A high index of suspicion and an early histopathologic examination are essential to not delay diagnosis.

Severity of episcleritis and systemic disease association

OBJECTIVE

To analyze patient characteristics and correlate between the site and severity of the inflammation and ocular and/or systemic disease association in a cohort of patients with episcleritis.

DESIGN

Retrospective case series.

METHODS

Medical records of 100 patients with episcleritis were reviewed. Data were analyzed using a customized database software.

RESULTS

The age range at presentation was 18 to 76 years (mean, 43; median, 44). Sixty-nine percent of the patients were female. Thirty-two (32%) patients had bilateral involvement. The episcleritis was nodular in 23 eyes (16%). Half of the patients had a concurrent eye disease. Associated systemic disease was found in 36 patients (36%). In two patients, episcleritis preceded a systemic vasculitic disease (Wegener granulomatosis and Cogan syndrome). Ocular complications included uveitis (11.4%), corneal involvement (15%), and glaucoma (7.8%). No significant correlation of the site and severity of inflammation to the presence of associated systemic or ocular diseases was found. The mean follow-up was 16.5 months. Twenty-eight patients experienced recurrence of episcleritis during the follow-up. Half of the patients required treatment with oral nonsteroidal anti-inflammatory drugs.

CONCLUSIONS

Episcleritis is usually a benign, self-limited disease, but it should not be trivialized since it may be associated with systemic disease and ocular complications. A careful review of systems should be performed in all patients presenting with episcleritis, and this should be repeated at least annually during the follow-up. A thorough eye examination is obviously essential to detect and treat ocular complications.

Conjunctival lymphoma masquerading as chronic conjunctivitis

OBJECTIVE

Malignant lesions of the conjunctiva may present with slowly evolving signs resembling inflammation. The authors describe the clinical and histopathologic findings of two patients with bilateral conjunctival lymphoma who presented with a history of chronic conjunctivitis without clinically noticeable subconjunctival nodules.

DESIGN

Case report.

PARTICIPANTS

Two patients.

INTERVENTION

Both patients underwent conjunctival biopsy for evaluation of persistent conjunctival inflammation that did not respond to various medical treatment methods.

RESULTS

Histopathologic examination revealed extranodal marginal zone B-cell lymphoma (mucosa-associated lymphoid tissue type) in one patient and follicle center lymphoma in the other patient. Both patients subsequently received radiation therapy and achieved a complete remission with no evidence of recurrence in the follow-up period of 20 and 16 months, respectively.

CONCLUSIONS

Conjunctival lymphoma should be included in the differential diagnoses of chronic conjunctivitis. Persisting signs and symptoms of conjunctivitis not responding to standard treatment should prompt biopsy.

Postoperative topical mitomycin C in conjunctival squamous cell neoplasia

PURPOSE

To report the efficacy of topical mitomycin C in preventing local recurrences after incomplete surgical excision of conjunctival squamous cell neoplasia.

METHODS

Four patients presented with unilateral conjunctival tumors. Excisional biopsy results revealed conjunctival intraepithelial neoplasia with an intact basement membrane. Neoplastic cells were present in at least one of the surgical borders of the excised conjunctiva in all four cases. Patients were treated with topical mitomycin C 0.02% three times daily for 2 weeks to prevent recurrences.

RESULTS

All four patients were free of clinically detectable tumors after a mean follow-up period of 20 months (range, 16-23 months). Side effects included mild discomfort, redness, photophobia, and punctate epithelial keratopathy that subsided on discontinuation of the medication.

CONCLUSION

Postoperative topical mitomycin C application may be a useful adjunct to prevent recurrences in patients with incompletely excised conjunctival squamous cell neoplasia.

Bilateral acute retinal necrosis caused by cytomegalovirus in an immunocompromised patient

PURPOSE

To report a case of bilateral acute retinal necrosis caused by cytomegalovirus.

METHODS

A diagnostic vitrectomy was performed on a patient with non-Hodgkin lymphoma who presented with a bilateral, rapidly progressing necrotizing retinitis and uveitis.

RESULTS

Immunohistochemical studies and polymerase chain reaction disclosed cytomegalovirus as the cause of retinitis. The patient was treated with intravitreal and intravenous ganciclovir.

CONCLUSIONS

Although rare, cytomegalovirus may lead to an appearance identical to acute retinal necrosis and should be considered among the viral etiologies of this syndrome.

Ocular rosacea: patient characteristics and follow-up

PURPOSE

The purpose of this report is to review the presenting symptoms and signs, treatment regimens used, complications encountered, and outcome in a cohort of patients with ocular rosacea.

METHODS

The medical records of 131 patients with a diagnosis of ocular rosacea were reviewed retrospectively. Data were entered in a tabulated form, and a descriptive analysis was performed.

RESULTS

The age range at presentation was between 23 and 85 years (mean, 56 years). Cutaneous manifestations of rosacea were present in 112 of the patients at their first visit. The most common presenting symptoms were foreign body sensation and burning, and the most common signs were telangiectasia and irregularity of lid margins, and meibomian gland dysfunction. Thirteen patients had decreased visual acuity at the time of presentation due to corneal complications. Six of these patients required penetrating keratoplasty during the course of their disease. Seven patients had severe cicatrizing conjunctivitis at the time of referral. One hundred thirteen patients were treated with oral tetracycline derivatives. Seven patients were left with visual acuity less than 20/400, and one patient underwent enucleation for corneal perforation and endophthalmitis.

CONCLUSIONS

Ocular rosacea is a common disease involving the skin and the eyes. It is widely underdiagnosed by many ophthalmologists despite the blinding potential. Successful therapy requires a multidisciplinary approach.