Stabilisation Of Pre Perforative Corneal Ulcer Complicating Advanced Rheumatoid Arthritis With Injection Of Infliximab : A Case Report.

Rheumatoid arthritis is the most common chronic inflammatory arthritis. It is an auto-immune disease, systemic and non-specific.

Ocular complications in Rheumatoid arthritis are mainly dry eye, scleritis and keratitis.

The incidence of central corneal ulcer is rare in Rheumatoid arthritis, and severe, due to the major risk of perforation. 

We report the case of a 37-year-old patient, followed for rheumatoid arthritis since 2018 under Salazopyrine and ARAVA , presented to the ophthalmological emergency room for painful red eyes with a profound drop in visual acuity in the two eyes.

The ophthalmological examination found a visual acuity of 4/10 (Snellen Chart) on the OR and HM on the OS.Slit lamp examination found purulent secretions on the OS. Examination of the left cornea found a peforated paracentral corneal ulcer, sealed by the iris ,and a second central corneal ulcer, pre-perforative and a superficial punctate keratitis.Fundus examination was not possible. Examination of the right cornea was characterized by the presence of diffuse superficial punctate keratitis and a pre-perforative para central ulcer.Fundus examination was normal.Mode B ultrasound of the left eye showed signs of endophthalmitis.The patient was put on fortified eye drops, lubricants, artificial tears, healing agents and general antibiotic therapy, followed, once the ocular infection was suppressed, by boluses of corticosteroids  and a therapeutic lens.A therapeutic keratoplasty was proposed but the patient refused the intervention.The evolution was marked by the aggravation of the symptomatology with the appearance of peripheral ulceration in the OR. The evolution in the left eye was marked by an anatomical and functional loss of the globe.In order to preserve the controlateral eye, a biological treatment: anti-TNF alpha was initiated. The evolution was favorable, with stabilization of the corneal lesions of the right eye, disappearance of the peripheral ulcerations and improvement of the ocular dryness. Visual acuity after 3 injections of Inflixumab was 7/10(Snellen chart). 

This is a case of an active rheumatoid arthritis complicated by central ulcerative keratitis which progressed to corneal perforation in the left eye and pre-perforated corneal ulcer of the right eye improved under Infliximab. Infliximab was effective both on the rheumatic attack and on the right corneal attack by preventing its evolution towards the perforation.

This case affirms findings from the literature regarding the efficacy of infliximab in the treatment of corneal ulcers complicating ulcerative keratitis secondary
 to rheumatoid arthritis.