Wessely Immune Ring Surrounding Contact Lens Related Corneal Infiltrate In A Patient With Behçet’S Syndrome.

Wessely rings are corneal intrastromal sterile infiltrates resulting from an immune response to foreign antigens, which diffuse from the limbal vasculature, leading to immune complex formation and polymorphonuclear leukocyte deposition into the stroma. They may be found in cases of infectious keratitis (herpes, pseudomonas, acanthamoeba, microsporidia) or in sterile conditions (chronic contact lens use, excimer laser photoablation, recurrent corneal erosions). We herein report a case of dense immune ring formation triggered by a contact lens related corneal infiltrate in a patient with autoimmune background.

Ophthalmology Department, Laiko General Hospital, Athens, Greece.

A 33 year old female contact lens user presented with redness and irritation in the right eye. Slit lamp examination revealed a peripheral corneal infiltrate, adjacent conjunctival hyperaemia and minimal reaction in the anterior chamber. Swabs were taken for microbiology and culture and the patient was started on topical empirical treatment with levofloxacin. Upon clinical improvement weak topical steroids (fluorometholone) were added two days later. The culture revealed infection with pseudomonas aeruginosa sensitive to levofloxacin and the corneal infiltrate disappeared a week later. Following gradual tapering and discontinuation of topical steroids there was a recurrence of the patient’s symptoms. This time slit lamp examination revealed a dense white Wessely immune ring in the peripheral stroma surrounding the infiltrate in a symmetric manner and anterior chamber cells (++). These clinical signs would improve with topical steroids, but recur every time after cessation of the drops despite the slow tapering. The patient had a history of bilateral erythema nodosum, oral and genital aphthae, and HLA-B27 positive arthritis. Rheumatology assessment concluded in  Behçet’s syndrome and the patient was started on systemic adalimumab which finally led to the gradual fading and resolution of the ring.

Wessely immune corneal ring may appear following pseudomonas corneal infection and may be notably persistent especially in patients with autoimmune background like Behcet’s syndrome. In our case the appearance of the Wessely immune ring contributed to the diagnosis of Behcet’s syndrome and also served as a sign of disease activity. As a result, the patient was started on systemic TNF alpha inhibitor, which helped the resolution of not only the ring, but also the patient’s systemic symptoms. To conclude, we recommend thorough investigation of a patient’s autoimmune background with the aid of a rheumatology assessment in case of a persistent Wessely immune corneal ring.