Management Of Peripheral Ulcerative Keratitis With Secondary Infectious Keratitis And Nodular Episcleritis In A Patient With Severe Rheumatoid Arthritis

To describe the diagnostic and therapeutic approach for severe refractory rheumatoid arthritis (RA) complications, including superinfected peripheral ulcerative keratitis (PUK) and nodular episcleritis. This case highlights the importance of close ophthalmologic follow-up in RA patients with ocular involvement.

Cornea and ocular surface clinic at our institution.

A 69-year-old woman with refractory RA on systemic immunomodulators and corticosteroids presented with three days of left eye (LE) pain and six months of bilateral irritation. Examination revealed bilateral 360º peripheral corneal thinning, with stromal infiltrate and epithelial defect in the LE. Corneal cultures were taken, and empirical treatment was initiated. After 48 hours, a corneal infiltrate appeared in the right eye (RE), leading to culture and treatment initiation. Culture tested positive for M. catarrhalis in the LE and negative in the RE, confirming bilateral PUK, superinfected in the LE. Three months later, the ulcer recurred in the LE, and after 30 days, nodular episcleritis developed in the RE, subsequently affecting the LE.

Progressive resolution of PUK was achieved with corneal healing and symptom relief. Nodular episcleritis showed a partial response to topical anti-inflammatory treatment, with controlled recurrences during follow-up. No complications such as corneal perforation or deep scleral involvement were observed.

Timely and individualized management of PUK in RA patients is crucial to preventing severe complications. Associated nodular episcleritis requires prolonged follow-up and treatment adjustments. A multidisciplinary approach is essential for optimizing patient outcomes.