Rosacea scleritis and sclero-uveitis; under recognised and over treated

Rosacea episcleritis, scleritis and uveitis may be missed when clinicians focus on the eye without appraising the adnexae and facial skin. Addressing rosacea can reduce treatment failures and avoid systemic complications of less effective or more toxic drugs. This series presents four cases with scleritis and / or sclero-uveitis in the setting of facial or ocular rosacea. Where relevant, negative systemic scleritis work up is included. Common features were incomplete resolution or poor response to one or more of topical and systemic steroid, systemic non-steroidal anti-inflammatory, systemic immunomodulatory and topical antibiotic treatment. All cases responded promptly to treatment with oral doxycycline, allowing withdrawal of other treatment. A review of the literature is presented, updating understanding of immunogenetics and inflammatory pathways relevant to ophthalmic management of these cases. Important considerations include the role of steroids, vitamin D, microbes, toll like receptors and their influence on the cathelicidin (Ll-17) pathway in rosacea inflammation. Making a correct rosacea diagnosis and managing with doxycycline or related medication can result in rapid remission, minimising disease complications and side effects of less targeted drugs.