Peripheral Ulcerative Keratitis In Rheumatoid Arthritis: Pluridisciplinary Urgent Kombat (Puk)

Peripheral ulcerative keratitis (PUK) is a rapidly destructive crescent area associated with loss of epithelial layer and stromal thinning. Rheumatoid arthritis accounts for 34% of non-infectious PUK, with bilateral involvement in 50% of patients. Even with topic and systemic treatment the visual prognosis is poor. However, biologic therapy is elevating the treatment of many auto-immune diseases and, therefore, patient’s prognosis. We inquire if biologic therapy is a tool to every patient and contemplate how can we manage the ones not fitted to this type of treatment.

Ophthalmology Department, Hospital de Egas Moniz – Unidade Local de Saúde de Lisboa Ocidental, Lisbon, Portugal.

The authors review a case of a 79-year-old female, who presented to the ophthalmology emergency department with photophobia, redness, and pain in the right eye (RE) for the past two days. The patient described a a similar episode two months prior, treated only with topical lubricants and bandage contact lens. Past medical history included Osteoporosis and Rheumatoid Arthritis (RA) controlled with methotrexate (MTX) (20mg/week) and prednisolone (PSL) 5 mg/day.

Demographic and clinical data were collected from consulting the medical records. The investigation was completed by corneal Scheimpflug tomography (Oculus Pentacam®).

Biomicroscopy of RE showed temporal conjunctival ciliary injection with adjacent corneal thinning and a previous nasal corneal perforation with iris tamponing. After discussion with Rheumatology, the patient was started on oral doxycycline 100 mg/day, PSL 1mg/kg/day and prophylaxis, oral vitamin C, oxytetracycline ointment, PSL eyedrops bid, preservative-free lubricant hourly and the dose of MTX was optimized.

At month 1 visit there was complete resolution of conjunctival hyperemia and thickening of the inferior cornea. Rituximab was considered for this patient, despite the high risk of infection but it was deferred due to favorable clinical evolution, after slow corticosteroid taper and without recurrence at month 6 of follow-up.

Effective treatment of peripheral ulcerative keratitis imposes a challenge, particularly in the presence of systemic disease, as RA. Therefore, an urgent referral and close collaboration with the Rheumatologist is mandatory. Systemic therapy’s optimization in the presence of such severe ophthalmologic manifestations should not be delayed, even after instituting topical therapy. It is also important to notice that the presence of extra-articular manifestations in RA, as ocular inflammation, can indicate a deteriorating basal vasculitic process, associated with an increase in 5-year mortality without aggressive management.