Perforated Peripheral Ulcerative Keratitis In An Undiagnosed Hiv Patient Managed With Tectonic Keratoplasty A Case Report.

To describe a rare case of perforated peripheral ulcerative keratitis as initial ocular manifestation in a 45 year old female, with undiagnosed HIV without any known underlying systemic disease, managed with tectonic Keratoplasty.

There are few reports in the literature about HIV being the cause of peripheral ulcerative keratitis, this being an atypical etiology of such disease.

A 45 year old female with no previous medical history, presented with tearing, purulent discharge, pain and significant visual loss predominating in the right eye.

At examination Visual acuity Right eye: hand motion.  Left eye: 20/100 (.) 20/50.

Slit Lamp Exam Right eye: hyperemic conjunctiva, flat anterior chamber, opaque cornea with four perforations on the periphery with prolapse of iris tissue, lens not visible. It was determined: peripheral ulcerative keratitis with perforation in the right eye. 

 Initial treatment with Vitamin C, Doxycycline and a consult to Rheumatology was made.  Workup for associated infectious or systemic autoimmune disease yielded no evidence of collagen vascular disorders. ELISA for HIV was reported to be positive, viral load by polymerase chain reaction (PCR) with 29,500 copies/mL, CD4 counts 382 cells/cu mm. Corneal scrapings for cultures negative, Ultrasound B scan with no scleritis signs were found, Sacroiliac joint and chest X-ray were normal. Diagnosis: HIV

 Patient was managed with tectonic keratoplasty of the right eye and pulses of intravenous methylprednisolone. Retroviral therapy was initiated, immunosuppressant topical (Ciclosporin) and systemic (Azathioprine) drugs, systemic steroids and topical treatment  with Timolol and Sodium hyaluronate as maintenance regim, visual and corneal thinning show no deterioration and inflammation remains under control, in current protocol to achieve visual rehabilitation with optical keratoplasty

HIV is a systemic infection which can emerge with an ocular manifestation such as peripheral ulcerative keratitis in previously asymptomatic patients. 

It is always important to consider infectious systemic diseases as a rare but possible etiology in this corneal pathology. 

The management of this disease requires the collaboration with Rheumatology for an adequate work up and establish the corresponding systemic treatment in order to achieve a successful keratoplasty and posterior visual rehabilitation