Unilateral Peri-Orbital Oedema and Mechanical Ptosis: An Unusual Case Presentation of Rosacea.

Introduction: Rosacea is an inflammatory skin condition that can present with varied ophthalmic manifestations. It is often overlooked by clinicians especially when unilateral in presentation leading to diagnostic delay and a resultant psychosocial impact. We aimed to present a unique case of ocular rosacea, highlighting the difficulty in therapeutic challenges and diagnoses in such rare cases. Case Presentation: A 64-year-old Caucasian man presented with a 9-month history of persistent painless swelling of the right upper eyelid and secondary ptosis. His ophthalmic examination, serology, and MRI were otherwise normal besides mild meibomian gland dysfunction. Punch biopsy results were inconsistent and initially led to a misdiagnosis of benign squamous papillomata and, later, a differential diagnosis of dermatomyositis. He was trialled on appropriate management for these conditions without any benefit. Repeat histopathology was suggestive of rosacea, and given the persistence of symptoms despite multiple treatments, he was successfully managed with a right upper lid debulking biopsy transcutaneous blepharoplasty. Histopathological analysis of the debulking biopsy confirmed the diagnosis of rosacea, with additional features indicative of lymphoedema. Upon follow-up, there was resolution of lid swelling. Conclusion: Due to the non-specific nature of isolated ocular rosacea presentations, it can be easily misdiagnosed and, therefore, should always be considered as a differential diagnosis in persistent peri-orbital oedema. It can additionally pose significant therapeutic challenges for ophthalmologists, underscoring the importance of improving our understanding of ocular rosacea. Further, we have shown the effectiveness of surgical debulking in its management.