Main Article Content
1) To describe the association between rheumatoid arthritis and corneal perforation.
2) To review the aetiology and management of rheumatoid arthritis -associated Peripheral ulcerative keratitis (PUK).
Patient and methods: A 35-year-old female presented with a five days history of decreased vision, pain, and watering and foreign body sensation in her left eye. She is a known case of Rheumatoid arthritis, which was quiescent at the time of presentation, and for which she is taking oral prednisolone, methotrexate, and etanercept and folic acid supplements. She never had any prior consultation with an ophthalmologist. The patients' visual outcomes and the development of any significant systemic complications were recorded. Slit-lamp examination in right eye showed mild meibomian gland dysfunction, central corneal thinning of about 60%, and also inferonasal thinning. Anterior chamber was of normal depth. Pupil was round and reacting, lens clear. Left eye had inferonasal corneal perforation, less than 2mm in maximum diameter, with iris prolapsed. There was no infiltration around the perforation and no corneal edema. Seidel test was positive in left eye. Corneal vascularization was noticed at 3’clock position. Anterior chamber was shallow with inferior iridocorneal touch. Pupil was peaked inferiorly, lens being clear. Patient was admitted to ward started oral Carbonic anhydrase inhibitors, T. acetazolamide 250mg, four times per day for five days and artificial tears hourly. Perforation was sealed with cyanoacrylate glue with bandage contact lens. Patient was discharged after week.
PUK associated with rheumatoid arthritis often has a poor visual outcome and its appearance may herald the transformation of a patient's RA into the systemic vasculitic phase. RA-associated PUK should be managed with aggressive immunosuppression if the associated morbidity and mortality are to be avoided.
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
2. Shiuey Y, Foster CS. Peripheral ulcerative keratitis and collagen vascular disease. Int Ophthalmol Clin. 1998 Winter. 38(1):21-32.
3. Ladas JG, Mondino BJ. Systemic disorders associated with peripheralcorneal ulceration. Curr Opin Ophthalmol. 2000;11:468–471.
4. Messmer EM, Foster CS. Vasculitic peripheral ulcerative keratitis. Surv Ophthalmol. 1999 Mar-Apr. 43(5):379-96. .
5. Foster CS, Sainz de la Maza M. Immunological considerations of the sclera. Foster CS, ed. The Sclera. 1st ed. New York: Springer-Verlag; 1993:33-58.
6. Gregory JK, Foster CS. Peripheral ulcerative keratitis in the collagen vascular diseases. Int Ophthalmol Clin. 1996 Winter. 36(1):21-30.9
7. Messmer EM, Foster CS. Vasculitic peripheral ulcerative keratitis. Surv Ophthalmol. 1999 Mar-Apr. 43(5):379- 13
8. Eiferman RA, Carothers DJ, Yankeelov JA Jr. Peripheral rheumatoid ulceration and evidence for conjunctival collagenase production. Am J Ophthalmol. 1979 May. 87(5):703-9.
9. Nolle B, Specks U, Ludemann J, et al. Anticytoplasmic autoantibodies: their immunodiagnostic value in Wegener granulomatosis. Ann Intern Med. 1989 Jul 1. 111(1):28-40
10. Garg A, De Rojas J, Mathews P, Hazan A, Lin J, Trief D, et al. Using Anterior Segment Optical Coherence Tomography to Monitor Disease Progression in Peripheral Ulcerative Keratitis. Case Rep Ophthalmol Med. 2018. 2018:3705753.
11. Squirrell DM, Winfield J, Amos RS. Peripheral ulcerative keratitis 'corneal melt' and rheumatoid arthritis: a case series. Rheumatology (Oxford). 1999 Dec. 38(12):1245-8. .
12. Sharma N, Sinha G, Shekhar H, Titiyal JS, Agarwal T, Chawla B, et al. Demographic profile, clinical features and outcome of peripheral ulcerative keratitis: a prospective study. Br J Ophthalmol. 2015 Nov. 99 (11):1503-8. .
13. Liegner JT, Yee RW, Wild JH. Topical cyclosporine therapy for ulcerative keratitis associated with rheumatoid arthritis. Am J Ophthalmol. 1990 May 15. 109(5):610-2.
14. abs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. 2000 Oct. 130(4):492-513
15. Thomas JW, Pflugfelder SC. Therapy of progressive rheumatoid arthritis-associated corneal ulceration with infliximab. Cornea. 2005 Aug. 24(6):742-4
16. Sharma N, Sinha G, Shekhar H, Titiyal JS, Agarwal T, Chawla B, et al. Demographic profile, clinical features and outcome of peripheral ulcerative keratitis: a prospective study. Br J Ophthalmol. 2015 Nov. 99 (11):1503-8
17. Pham M, Chow CC, Badawi D, Tu EY. Use of infliximab in the treatment of peripheral ulcerative keratitis in Crohn disease. Am J Ophthalmol. 2011 Aug. 152(2):183-188.e2.
18. Korsten P, Bahlmann D, Patschan SA. Rapid healing of peripheral ulcerative keratitis in rheumatoid arthritis with prednisone, methotrexate and adalimumab combination therapy. Rheumatology (Oxford). 2017 Jul 1. 56 (7):1094.
19. Huerva V, Sanchez MC, Traveset A, Jurjo C, Ruiz A. Rituximab for peripheral ulcerative keratitis with wegener granulomatosis. Cornea. 2010 Jun. 29(6):708-10.
20. Albert M, Beltrán E, Martínez-Costa L. [Rituximab in rheumatoid arthritis-associated peripheral ulcerative keratitis]. Arch Soc Esp Oftalmol. 2011 Apr. 86(4):118-20. .
21. Ebrahimiadib N, Modjtahedi BS, Roohipoor R, Anesi SD, Foster CS. Successful Treatment Strategies in Granulomatosis With Polyangiitis-Associated Peripheral Ulcerative Keratitis. Cornea. 2016 Nov. 35 (11):1459-1465.
22. Lambiase A, Sacchetti M, Sgrulletta R, et al. Amniotic membrane transplantation associated with conjunctival peritomy in the management of Mooren's ulcer: a case report. Eur J Ophthalmol. 2005 Mar-Apr. 15(2):274-6.
23. Galor A, Jabs DA, Leder HA, et al. Comparison of antimetabolite drugs as corticosteroid-sparing therapy for noninfectious ocular inflammation. Ophthalmology. 2008;115:1826–1832.
24. Jabs DA, Rosenbaum JT, Foster CS, et al. Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel. Am J Ophthalmol. 2000;130:492–513.
25. Odorcic S, Keystone EC, Ma JJ. Infliximab for the treatment of refractory progressive sterile peripheral ulcerative keratitis associated with late corneal perforation: 3-year follow-up. Cornea. 2009;28:89–92.