RHEUMATOID ARTHRITIS REVEALED BY ATYPICAL BILATERAL KERATOPATHY

To describe the diagnostic approach in the presence of an atypical keratopathy (peripheral corneal thinnong) and its management.

Rheumatoid arthritis is a multisystem autoimmune disease that usually damages the synovial-lined joints. Extra-articular manifestations have been described in multiple organs, including the eye. Ocular involvement can range from milder conditions such as keratoconjunctivitis and episcleritis, to potentially blinding diseases such as scleritis and destructive corneal lesions.

We report the case of a patient who presented a bilateral peripheral corneal thinning without inflammatory signs evolving progressively for 6 years and posing a diagnostic difficulty due to the atypicality of the lesions as well as a therapeutic problem due to the imminent perforative risk.

 The patient was 50 years old and had a general history of polyarthralgia. She consulted us for a progressive bilateral visual impairment with irritative symptoms. On examination, the visual acuity was 9/10 in the right eye and 6/10 non-improvable in the left eye with a significant astigmatism of 9 diopters. Anterior segment examination revealed bilateral asymmetric marginal peripheral thinning lesions with lipid deposits and neovascularization in both eyes. The rest of the examination was unremarkable. Anterior segment oct showed intact epithelial and endothelial layers, anterior stromal melting with hyperreflective edging. The first-line immunological workup showed positive anti-ccp antibodies. After a specialized rheumatological examination, the diagnosis of rheumatoid arthritis revealed by corneal involvement was retained. 

In the absence of signs of activity suggestive of rheumatoid arthritis, the etiological diagnosis of corneal damage may be difficult. Indeed, the sequelae generated during the scarring phase may mimic degenerative, autoimmune or infectious lesions. Thus, coordination between ophthalmologists and rheumatologists is essential in order to make the appropriate diagnosis and to guide the therapeutic management.