Rosacea keratitis is an inflammatory infiltrative lesion of the cornea associated with pink acne of the facial skin. Rosacea keratitis is accompanied by corneal syndrome, the phenomena of mucopurulent conjunctivitis and iritis, the appearance of infiltrates and ulcers on the cornea, which develop against the background of rashes on the skin of the face. Diagnosis is based on biomicroscopy, visometry, instillation test with fluorescein solution, demodex examination. Treatment is carried out by an ophthalmologist and dermatologist; it requires the appointment of corticosteroids in the form of drops, ointments, subconjunctival injections; mydriatics, B vitamins, physiotherapy. In complicated cases, keratoplasty is performed.
Rosacea keratitis, along with filamentous keratitis and corrosive corneal ulcer, refers in ophthalmology to endogenous keratitis of unclear etiology. This form of the disease is pathogenetically closely related to a chronic inflammatory disease of the skin of the face – pink acne (rosacea). At the same time, 50% of patients develop rosacea keratitis after, and 20% – before the appearance of skin rashes; in some cases, the skin and eyes are affected simultaneously. Disease has a recurrent progressive course and can lead to blindness in the outcome.
The causes of rosacea keratitis, as well as the skin disease acne rosacea, are unknown. It is assumed that a certain role in the etiopathogenesis of rosacea keratitis is played by gastrointestinal diseases (gastritis with reduced or increased acidity, spastic colitis, cholecystitis, helicobacter infection), endocrinopathies (diabetes mellitus, pituitary insufficiency, hypothyroidism, adrenal insufficiency, dysmenorrhea), neurovegetative disorders (vegetative-vascular dystonia, hypertension), heredity. In recent years, the etiological role of demodex mites in the etiology of pink acne and rosacea keratitis has been widely discussed. The connection of rosacea keratitis with vitamin deficiency – hypovitaminosis B6, B12 has been proven.
The provoking factors may be excessive insolation, cold, stress, eating habits (alcohol abuse, spicy and spicy foods, hot drinks), physical activity, oral contraceptives, menopause, etc.
Clinically, rosacea keratitis can occur in the form of superficial marginal infiltrate, subepithelial infiltrate and progressive corneal ulcer. The superficial form of rosacea keratitis is characterized by the formation of grayish-white infiltrates at the limb, which slightly rise above the surface of the cornea and contain a bundle of superficial vessels. During the disintegration of infiltrates, ulcers are formed, which after epithelialization leave minor corneal opacities.
Subepithelial infiltrates are located under the corneal epithelium in the form of small convex nodules of gray color. The disintegration of nodules is accompanied by ulceration, vascularization and deposition of calcium salts, resulting in the formation of chalky turbidity. Progressive rosacea keratitis proceeds with the formation of an extensive ulcer with a roller-like raised edge. Rough newly formed vessels stretch to the other, flat edge of the corneal ulcer.
This disease characterized by bilateral localization and recurrent progressive course. Corneal lesion always develops against the background of rashes (pink acne) on the skin of the face.
Clinically, rosacea keratitis is manifested by a pronounced corneal syndrome: burning and pain in the eyes, conjunctival hyperemia, lacrimation and photophobia. There is a mixed injection of the eyeball, mild conjunctivitis with mucopurulent discharge, telangiectasia on the skin of the eyelids. Often rosacea keratitis is accompanied by chronic blepharitis and chalazions. In severe cases, iritis, scleritis, hypopion develops.
Rosacea keratitis is combined with skin manifestations in the facial area. They include erythema of the cheeks, nose, forehead; telangiectasia; peeling, burning and tingling of the skin; papulo-pustular rashes of bright red color; hypertrophic skin changes of individual parts of the face (rhinophyma, metophyma, blepharophyma, otophyma, gnathophyma).
Exacerbation of rashes of pink acne on the face causes a new attack of rosacea keratitis. Each subsequent infiltration of the cornea leads to a deepening of the ulcerative defect, the ingrowth of new vessels and more extensive scarring. Progressive corneal ulcer leads to thinning or melting of the cornea of the eye. Each new exacerbation of rosacea keratitis is accompanied by an even greater deterioration of vision.
When diagnosing rosacea keratitis, the connection of ocular manifestations with rosacea acne is always taken into account. Therefore, therapeutic and diagnostic measures should be carried out jointly by an ophthalmologist and a dermatologist.
Ophthalmological examination for rosacea keratitis consists in carrying out biomicroscopy of the eye using a slit lamp, endothelial and confocal microscopy of the cornea, pachymetry, computer keratometry. Defects of the corneal epithelium are detected during the instillation fluorescein test. Visometry is performed to assess the severity of the lesion and the degree of visual acuity reduction.
For the purpose of differential diagnosis of the etiology of keratitis, scraping of the corneal epithelium with its subsequent cytological examination is shown. To exclude demodicosis of the eyelids, they resort to eyelash epilation and their examination for demodex.
If necessary, a gastroenterologist, endocrinologist, neurologist are involved in the examination of patients with rosacea keratitis.
Topical therapy includes the use of corticosteroid drugs (hydrocortisone, dexamethasone, prednisone) in the form of instillations, ointment applications, subconjunctival injections. Topically, instillation of vitamins (citral, riboflavin) into the conjunctival cavity, laying gels accelerating repair, thiamine and insulin ointments behind the lower eyelid is prescribed. In order to prevent iridocyclitis, mydriatics are instilled into the eyes.
When secondary infection is layered, the use of sulfonamides, antibiotics (tetracycline, levomycetin, penicillin) in the form of eye ointments and drops is indicated. Electrophoresis with diphenhydramine and riboflavin alternately for a month has a good therapeutic effect in rosacea keratitis, followed by electrophoresis of ascorbic acid and hydrocortisone. As part of the complex treatment of rosacea keratitis, perilimbal or perivasal novocaine blockades are performed.
General therapy includes taking antihistamines, biogenic stimulants, multivitamins. During periods of exacerbations, a carb-free, salt-free diet is recommended.
In order to accelerate the epithelization of defects, scraping and extinguishing of areas of corneal inflammation, cauterization of dilated vessels is performed. With complicated corneal ulcer, through keratoplasty is indicated.
In parallel with ophthalmological manifestations, skin rashes are treated (cryotherapy, laser therapy, medication courses), concomitant pathology of the gastrointestinal tract, endocrine organs, and rehabilitation of focal infection.
Prognosis and prevention
The recurrent course leads to corneal opacities of varying intensity, which inevitably affects visual acuity. Due to the fact that rosacea keratitis occurs in a chronic form, one should try to avoid factors that provoke exacerbation: overheating, hypothermia, errors in nutrition, etc. It is necessary to systematically monitor patients with rosacea acne by a dermatologist and an ophthalmologist.