Penetrating Keratoplasty After Repeated Conjunctival Autograft In Patient With Rheumatoid Arthritis

To present a case involving a patient with severe ocular surface disease due to rheumatoid arthritis, who was previously managed with multiple conjunctival flap surgeries.

Quito, Ecuador 

A 71-year-old male patient with best corrected visual acuity of light perception in his right eye and 20/20 in his left eye, with a past medical history of rheumatoid arthritis in treatment with leflunomide and methotrexate, visited our clinic for evaluation.
Under examination, he had symblepharon of the upper eyelid, ocular surface granuloma, athalamia and aphakia due to previous multiple conjunctival flap surgeries. Additionally, meibomitis and vasodilatation at the eyelid margin and nasal region were noted.
A surgical intervention was performed, which included the release of symblepharon and removal of the granuloma. Then, a penetrating keratoplasty was performed, with a trephination of the donor cornea of 8.5 mm and 8.0 mm of the recipient cornea, which was challenging due to significant hypotonia and anterior synechia of the iris. Reformation of the anterior chamber, pupilloplasty and anterior vitrectomy was required. After several months, a monofocal intraocular lens was securely fixed to the iris without complications, and with a follow up of 24 months, the patient mantains BCVA of 20/50 in his right eye.

Ocular surface alterations are closely related to diseases such as rheumatoid arthritis, rosacea and meibomian gland disease. Diagnosis and clinical treatment are key in order to prevent corneal ulcers from progressing with corneal thinning and perforation with serious vision compromise. The conjunctival flap should be used in corneal refinements without corneal perforation.
Tectonic corneal transplants are indicated to restore ocular integrity in perforated corneas, providing a more permanent solution with the option of recovering vision. These challenging cases have a higher incidence of corneal rejection, therefore, it is essential to treat underlying pathologies and perform routine follow-ups.