Rosacea is a chronic inflammatory disorder mainly involving midline facial skin and neck, with onset in the age group of 30-50 years, with preponderance in females than males. Skin involvement varies from flushing, erythema, telangiectasia, papules, and pustules to phymatous changes. Common ocular manifestations include meibomian gland dysfunction, lid telangiectasias, conjunctival hyperemia, blepharoconjunctivitis. Left untreated can lead to peripheral corneal vascularization, infiltrates, thinning and perforation [1]. Although ocular involvement is common, complications occur only in 6-18% of patients [2]. Ocular Rosacea is a relatively common condition that is often underdiagnosed and untreated. This case report is presented to stress on the importance of early diagnosis and treatment especially when cornea gets involved as it may lead to blindness if not treated in time.

Thirty-Four years old male presented to the outpatient department with redness, watering, photophobia left eye for 2 weeks. There was a history of skin lesions over the face which had worsened for the last 3 weeks. Slit Lamp Examination of the left eye showed circumcorneal congestion, two subepithelial infiltrates, both measuring 2×2 mm, one perilimbal at around 5 o’clock and other paracentral at 4 o’clock with superficial corneal vascularization. (Figure 1) Both eyes had posterior blepharitis with eyelid margins showing telangiectasias and erythema. Both eyes had interpalpebral conjunctival hyperemia. Visual Acuity in the right eye was 6/9 and 6/24 in the left eye. The posterior segment of both eyes was normal. Schirmer’s test was 10 mm right eye and 7 mm in the left eye.

Ocular and facial manifestations most commonly develop simultaneously, but at times ocular signs precede skin changes wherein it is frequently misdiagnosed. Both eyes are usually affected simultaneously, but unilateral or sequential involvements can occur. A common ocular manifestation of rosacea ranges from blepharitis, conjunctival injection, eyelid margin telangiectasias, meibomian gland dysfunction such as chalazion or stye to sight-threatening complications like corneal ulceration, vascularization, and perforation [4].

Corneal alterations are detected in 25–50% of patients with ocular rosacea and may range from mild punctate epithelial keratitis accompanying the blepharoconjunctivitis to corneal vascularization, infiltration, ulceration, and perforation. Peripheral corneal infiltrates/vascularization and superficial punctate keratitis, usually involving the inferior half of the cornea, are the most common corneal findings.

Characteristically, there is the vascular invasion of the peripheral cornea with subepithelial infiltrates along the advancing vascular border. These infiltrates can progress circumferentially or toward the central cornea. The infiltrates may be followed by corneal vascularization and may compromise the visual axis. This condition may also be associated with significant peripheral thinning and asymmetric astigmatism which also impairs vision. Severe corneal inflammation can lead to corneal melting and even perforation.

Duke-Elder reported that blepharitis in every case of rosacea eventually appears and sometimes spread to conjunctiva assuming diffuse hyperemic type and rarely nodular conjunctivitis. Nodular episcleritis near limbus and rosacea keratitis with marginal ulcer occurs as an extension of Rosacea. Conjunctivitis frequently accentuated in lower quadrants. This may be associated with punctate keratitis and later on subepithelial infiltrates develop. Numerous scars, horseshoe-shaped, or tongue-shaped, develop with the apex directed toward the center of the cornea [5].

The detailed etiology and pathophysiology of ocular and cutaneous rosacea remain unclear, although it is commonly thought of as an inflammatory process. Another hypothesis states that rosacea is dermal dystrophy where there occur degenerative changes in perivascular collagen causing small vessel dilatations and in due course incompetence of vessels.