Ocular Rosacea Keratitis Presenting With Granulomatous Keratic Precipitates: An Immune-Mediated Masquerader Of Granulomatous Anterior Uveitis

To report an uncommon inflammatory presentation of ocular rosacea manifesting as stromal keratitis associated with granulomatous (mutton-fat) keratic precipitates (KPs), which may clinically simulate infective or immune-mediated keratouveitis and lead to delay in appropriate anti-inflammatory therapy.

Tertiary Eye Care Centre, Chandigarh, India

A 30-year-old male presented with redness, photophobia, watering, and progressive vision loss in the right eye for 1 month. Slit-lamp examination showed localized anterior stromal infiltrate, epithelial irregularity, surrounding stromal haze, and large granulomatous mutton-fat keratic precipitates with mild anterior chamber reaction. Corneal sensation was intact. Ocular surface findings included meibomian gland dysfunction and telangiectatic lid margins. Dermatological examination indicated rosacea with centrofacial erythema, papulopustular lesions, and telangiectasia. Systemic evaluations, including chest imaging and serum tests, ruled out other causes. A diagnosis of ocular rosacea–associated granulomatous keratitis was made.

The patient was initiated on oral doxycycline 100 mg once daily along with topical predacetate 1% in tapering dosage, preservative-free lubricants, and adjunctive lid hygiene measures including warm compresses and lid margin cleansing.Progressive resolution of stromal inflammation was observed over a period of three weeks, accompanied by marked reduction in endothelial keratic precipitates and anterior chamber activity.Cutaneous facial erythema and papulopustular lesions also showed improvement with systemic tetracycline therapy. No recurrence of keratitis or intraocular inflammation was noted over a follow-up period of two months.

Ocular rosacea may rarely present with granulomatous keratitis characterized by mutton-fat keratic precipitates, thereby mimicking infective keratouveitis or immune-mediated anterior uveitis. Recognition of associated lid margin disease and concurrent facial cutaneous rosacea is essential for accurate diagnosis. Early initiation of systemic tetracycline therapy combined with topical corticosteroids results in favorable clinical outcomes. A high index of suspicion is necessary in cases of stromal keratitis with negative microbiological work-up to prevent misdiagnosis and unnecessary antimicrobial therapy.