What is the next step for a patient with progressive facial erythema (redness) now involving the eye, potentially indicating conditions like rosacea or an allergic reaction?

Progressive Facial Redness with Eye Involvement: Urgent Ophthalmology Referral Required

Refer immediately to ophthalmology for slit-lamp examination to rule out bacterial keratitis, ocular rosacea with corneal involvement, or other sight-threatening conditions. 1, 2

Immediate Assessment for Life-Threatening Causes

Before considering benign dermatologic conditions, exclude anaphylaxis if the patient presents with:

• Acute onset with skin/mucosal involvement plus respiratory compromise or reduced blood pressure 2
• Accompanying urticaria, angioedema, pruritus, or tachycardia 2
• If suspected, administer epinephrine 0.3 mg intramuscularly into the mid-outer thigh immediately—delayed administration increases mortality risk 2

Most Likely Diagnosis: Ocular Rosacea

The progressive nature of facial erythema now involving the eye strongly suggests ocular rosacea, which requires urgent ophthalmologic evaluation to prevent corneal complications. 1, 2, 3

Key Diagnostic Features to Identify

Facial findings that confirm rosacea:

• Central facial erythema involving malar and nasal areas 3, 4
• Telangiectasia (visible blood vessels) 4, 5
• History of easy facial flushing or blushing 2, 4
• Papules, pustules, or prominent sebaceous glands 2, 4
• Rhinophyma in advanced cases (nasal skin thickening) 3, 5

Ocular manifestations requiring urgent attention:

• Blepharitis (eyelid margin inflammation with crusting) is the most common ocular finding 1, 3
• Conjunctivitis with burning and grittiness 3, 4
• Meibomian gland dysfunction 1
• Corneal involvement including infiltrative keratitis—this is sight-threatening 1

Critical Pitfall to Avoid

Do not dismiss recurrent eye symptoms as simple conjunctivitis in patients with facial redness—ocular rosacea can cause bacterial keratitis and corneal infiltrates that threaten vision. 1 Severe ocular rosacea is specifically listed as a risk factor for infectious keratitis in the most recent ophthalmology guidelines. 1

Differential Diagnoses to Consider

While ocular rosacea is most likely given the progressive facial-to-ocular pattern, also evaluate for:

Infectious keratitis:

• Bacterial, fungal, or Acanthamoeba keratitis can present with progressive eye involvement 1
• Risk factors include contact lens wear, corneal trauma, or chronic ocular surface disease 1
• Requires urgent cultures and empiric antibiotic therapy if suspected 1

Medication-induced causes:

• Systemic retinoids (isotretinoin) cause severe dry skin, blepharitis, and increased Staphylococcus aureus colonization 2, 6
• Dupilumab causes conjunctivitis, keratitis, and blepharitis in 32-55% of patients 2
• Topical glaucoma medications, NSAIDs, or preservatives can cause keratoconjunctivitis 7

Allergic conditions:

• Vernal or atopic keratoconjunctivitis can cause corneal infiltrates 1
• Distinguished by bilateral involvement, watery/mucoid discharge, and atopic history 1, 7

Immediate Next Steps

1. Urgent ophthalmology referral for slit-lamp examination to assess for:

   • Corneal infiltrates or ulceration 1
   • Depth of corneal involvement using optical coherence tomography if needed 1
   • Meibomian gland dysfunction using meibomography 1
   • Keratoconus screening (increased risk in allergic/rosacea patients) 1

2. Obtain detailed medication history:

   • Recent initiation of isotretinoin, dupilumab, or topical eye medications 2, 6, 7
   • Discontinue offending agent if medication-induced cause identified 2

3. Document trigger exposures:

   • Alcohol consumption (especially if patient has ALDH2 deficiency with flushing, tachycardia, and reduced alcohol tolerance) 2
   • Spicy foods, temperature extremes, stress 3, 4
   • Contact lens wear or poor lens hygiene 1

Treatment Approach Once Diagnosis Confirmed

For ocular rosacea with eye involvement:

• Eyelid hygiene with warm compresses and lid scrubs 1, 4
• Oral doxycycline (systemic tetracyclines are first-line for ocular rosacea) 1, 4, 5
• Topical cyclosporine 0.05% may benefit some patients 1, 4
• Topical metronidazole or azelaic acid 15% gel for facial lesions 4, 5, 8
• Brimonidine 0.33% gel for persistent facial erythema 4, 5, 9

If bacterial keratitis is diagnosed:

• Empiric broad-spectrum topical antibiotics immediately 1
• Corneal cultures before initiating therapy when possible 1
• Close ophthalmologic follow-up to monitor response 1

Warning Signs Requiring Emergency Evaluation

• Severe eye pain disproportionate to findings (suggests Acanthamoeba keratitis) 1
• Rapid vision loss 1
• Corneal opacity or infiltrate visible on examination 1
• Photophobia with contact lens wear 1
• Systemic symptoms suggesting anaphylaxis 2