PERIPHERAL ULCERATIVE KERATITIS (PUK) IN RHEUMATOID ARTHRITIS

Peripheral ulcerative keratitis or Mooren's pseudo-ulcers is a corneal manifestation of a general pathology affecting the small vessels.(1)  Its treatment is determined by the severity of the corneal damage and the activity of the vasculitis. (2) We report the case of a woman who presented  with rheumatoid arthritis complicated by peripheral ulceration and who responded well to treatment. (2)(3)(4)

Peripheral PUK corneal ulcers in autoimmune diseases are similar to Moran's ulcers in all respects. They are the corneal manifestation of a general pathology affecting the small vessels: vasculitis. The periphery of the cornea, limbus, includes a terminal vascularization . This is the source of inflammatory cell infiltration and a preferred site for the deposition of circulating immune complexes. (6)(7)(8) .Peripheral ulcerative keratitis (PUK) is a rare and is associated with high mortality. P(PUK) manifests as eye pain, redness, photophobia, and thinning and opacity of the peripheral cornea. The most serious complications are perforation and vision loss.treatment of PUK begins with topical corticosteroid therapy. If there is resistance to corticosteroids ,Systemic treatment is usually considered, including high-dose corticosteroid therapy and treatment with immunosuppressive agents or biotherapy. (5) The use of adhesive fabrics and therapeutic lenses can prevent of corneal melting. multilayer amniotic membrane grafting takes a large place. (9)(3)

82 year old female patient, followed for 15 years for rheumatoid arthritis.The patient presented since one week of her admission with a painful red eye with visual acuity decrease. The ophthalmological examination objectives: Visual acuity of 2/10 in the left eye. Biomicroscopic examination showed a clean, preperforative,marginal corneal ulcer of the left eye with peripheral neovascularization . The bacteriological sample was normal. Patient initially put on : Healing treatment based on artificial tears, preventive local antibiotic coverage, and under corticoid eye drops initially then under conjunctival injection of corticoid, with installation of therapeutic lens aimed at analgesia. The patient was put on a full dose of oral corticosteroids.The evolution was marked by a decrease in redness and ocular pain, with the beginning of healing of the ulceration after the 2nd subconjunctival injection.

 

Detection of corneal complications in inflammatory diseases is a factor in poor   prognosis, especially in the case of ulcers. Sterile corneal ulcers are rare but can be a serious complication of rheumatoid arthritis. Our study illustrates a case that responded well to corticosteroid therapy. this Case confirmed the literature findings on the efficacy of corticosteroids in the treatment of corneal ulcers secondary to peripheral ulcerative keratitis in rheumatoid arthritis.