The Mystery Of Corneal Ring Infiltrates..!

To discuss a case of ring infilterate of cornea with bilateral ocular surface inflammation.

Tertiary care multispecialty medical education and research institution.

A 24/Male, presented with chief complaints of severe pain, redness, irritation, photophobia in eyes since x 3.5 years. He was diagnosed as ring infiltrate unproven Acanthamoeba keratitis, elsewhere. he was treated on topical antibiotics, Voriconazole and artificial tears, was not responding to the treatment. Symptoms were worsening then referred to us.

On examination-  BCVA was Hand movements and 6/36 in right and left eye respectively. Both eyes had severe conjunctival congestion. There was large subtotal epithelial defect along with stromal ring infiltration in Right eye. Left eye had small epithelial defect of size 3x4 mm.  Initial look of right eye suggestive of  ring infilteration of infective diseases . However, we could appreciate some amount of  forniceal sub conjunctival scarring. 

• Microbiology of the corneal scraping was not suggesting any microbial infection.
• Retrospective history revealed history of recurrent oral mucosal ulcers.
• Dermatology opinion was sought which was s/o of mucous membrane pemphigoid.

Conjunctival biopsy was sent.

Conjunctival biopsy sent for immuno-histo-chemistry reported linear IgG deposits along the BMZ, diagnostic of  Ocular MMP/OCP.

Subsequently patient was treated with systemic and local steroids.

IV methyl prednisolone 1gram X 3 doses for 3 days.

• Oral steroids 40mg 1OD
• Top antibiotics and steroids x 6 times.

Oral Mycophenolate Mofetil therapy was also started after screening of systems.

Final follow up at 6 weeks - BCVA- 6/36 and 6/12.

Ocular cicatricial pemphigoid may present in varied clinical presentations even as corneal ring infiltrate, treating ophthalmologist should keep high index of suspicion. Detailed ocular examination comprehensively along with a detailed look into systemic complaints can clinch the diagnosis.