Not So Herpes: The Importance Of Eyelid Examination - A Case Report

Rosacea is a chronic inflammatory dermatosis characterized by recurrent episodes of flushing, transient or persistent erythema, papules, pustules and telangiectasia. Multiple factors can trigger exacerbations. Some studies report that ocular involvement occurs in about half of patients with rosacea, including dryness, photophobia, conjunctivitis, blepharitis and, rarely, keratitis that might threaten visual acuity. Ocular rosacea may occur regardless of severity of cutaneous manifestations. This case report highlights the importance of careful eyelid examination, as periocular manifestations may be crucial in establishing definitive diagnosis.

Ophthalmology Department, Unidade Local de Saúde de São João, Porto, Portugal.

A 12-year-old boy came to the emergency department with a 1-week history of red right eye (OD) and decreased vision, previously diagnosed elsewhere as recurrent ocular herpes. Best-corrected visual acuity (BCVA) was hand motion in OD. Examination showed peri-nasal vesicular-like skin lesions, conjunctival hyperemia, punctate superficial keratitis, diffuse corneal haze, and 360º corneal neovascularization with central extension. It was prescribed oral acyclovir and cloranphenicol ointment and the patient was referred to the Cornea Department. On further evaluation, a history of recurrent red eye and chalazia was elicited.

Eyelid findings included meibomian glands inspissation, and telangiectasias. Ocular rosacea causing chronic blepharitis was considered the presumptive diagnosis and patient was treated accordingly (oxytetracycline ointment, tobramycin and dexamethasone eye drops and an artificial tear with a lipidic component). Seven days later, OD BCVA was 20/200. Anterior segment evaluation showed an improvement in blepharitis. Aciclovir was stopped at this point. Three months after the emergency department evaluation, OD BCVA was 20/100. Anterior segment assessment revealed only mild neovascularization in the inferior cornea, and anterior chamber details were completely visible. A topography was performed and revealed a 10-diopter irregular astigmatism.

This case illustrates the diagnostic challenge of pediatric ocular surface disease and the risk of anchoring bias in the setting of a prior diagnosis of herpetic keratitis. Careful history-taking and meticulous eyelid examination were pivotal, as recurrent red-eye episodes, chalazia, blepharitis, telangiectasia, and meibomian gland dysfunction supported the diagnosis of ocular rosacea with severe keratitis. Recognition of the underlying process enabled appropriate corticosteroid-based management, with important implications for visual prognosis and prevention of future relapses.