A 51-year-old African American man presented with bilateral eye pain and redness of four months' duration. Patient denied ocular problems previously. His prior medical history was significant for rosacea, for which he was not receiving any medical treatment. His review of systems was positive for bilateral eye pain and tender facial papules and pustules. He denied family history of autoimmune diseases or eye diseases. He denied promiscuous sexual activity, exposure to tuberculosis, or illicit drug use. His external exam was consistent with multiple medium to large erythematous papules, pustules with rhinophyma (Figure 4).
A skin biopsy was done and it revealed disrupted follicles with surrounding mixed suppurative and granulomatous dermatitis most suggestive of acneiform processes including ruptured folliculitis and rosacea. The patient was started on doxycycline 100 mg twice daily and topical metronidazole 1% cream twice daily.
His visual acuity was 20/400 in the right eye and 20/30 in the left eye. Slit lamp exam showed severe bilateral conjunctival injection, corneal pannus associated with inferonasal peripheral corneal thinning, and stromal scarring. His right eye showed an inferior 3 mm light-blocking infiltrate with overlying 3 mm epithelial defect.
Peripheral ulcerative keratitis (PUK) was suspected and oral prednisone 60 mg was started. An extensive autoimmune workup was done. All results were negative. Cornea was scraped for gram stain, bacterial cultures, and fungal cultures. The patient was started on topical hourly fortified vancomycin (25 mcg/mL) and tobramycin (15 mcg/mL). The patient continued to worsen and within two weeks developed right eye inferior corneal perforation, for which adjacent conjunctival resection, glue, and a bandage contact lens were applied (Figure 5). Topical fortified vancomycin (25 mcg/mL) and tobramycin (15 mcg/mL) were given at a lower rate of six times daily. Oral treatment consisted of doxycycline 100 mg twice daily and 60 mg of prednisone for one week that was tapered by 20 mg on a weekly basis. Close follow-up showed slow improvement afterwards. After four weeks of treatment, the corneal infiltrate resolved. The patient provided his informed consent prior to publishing this information.