Alcohol-Triggered Periocular Flushing Associated With Tacrolimus 0.1% Ophthalmic Solution in Sjögren-Related Ocular Surface Disease

Purpose: The objective of this study was to report alcohol-triggered periocular flushing during treatment with tacrolimus 0.1% ophthalmic solution instilled into the conjunctival sac for Sjögren-related ocular surface disease. Methods: A 46-year-old woman with severe dry eye disease refractory to standard therapy was treated with tacrolimus 0.1% ophthalmic solution, instilled twice daily, into the inferior conjunctival fornix of both eyes. Clinical response, onset of periocular symptoms, and their temporal relationship with alcohol ingestion were evaluated, excluding alternative causes of flushing. Results: Four weeks after treatment initiation, the patient developed recurrent, sharply demarcated periocular erythema and burning within minutes of ingesting small amounts of beer or wine. The episodes were reproducible, localized to the periocular region, and resolved spontaneously within approximately 1 hour without systemic manifestations. Avoidance of alcohol prevented recurrence while tacrolimus therapy was continued. Conclusions: Alcohol-triggered flushing, previously reported mainly with dermatologic calcineurin inhibitor formulations, may also occur during treatment with tacrolimus ophthalmic solution. Recognition of this self-limited reaction may prevent misdiagnosis and unnecessary discontinuation of an effective therapy.