Can Appropriate Systemic Treatment Help Protect the Cornea in Patients With Rheumatoid Arthritis? A Multidisciplinary Approach to Autoimmune Ocular Involvement

Assessment of corneal parameters in patients with rheumatoid arthritis

PURPOSE

To assess the corneal parameters in rheumatoid arthritis (RA) patients.

METHODS

We enrolled 64 patients with RA (32 receiving biologic and 32 receiving conventional drugs) and 32 healthy subjects. Keratometric values (anterior flat [K1], steep [K2], and mean keratometry [Km]), corneal thickness from the pupil center (CCT), apex (ACT), and the thinnest point (TCT), and corneal volume (CV) were measured and compared between the groups.

RESULTS

K1, K2, and Km values were significantly higher in the RA group (P = 0.013, P = 0.048, P = 0.027, respectively). The means of CCT, ACT, TCT, and CV were significantly lower in RA patients (P < 0.001, P < 0.001, P < 0.001, P = 0.011, respectively). When we divided RA patients into two groups according to the treatment and compared them to controls, the differences in K1, CCT, ACT, TCT and CV were significant (P = 0.030, P = 0.005, P = 0.001, P = 0.001, P = 0.034, respectively). K1 and CV values of RA-biologic group were similar to the control group (P = 0.205 and P = 0.127, respectively).

CONCLUSION

Biologic agents contribute to the improvement of K1 and CV values in patients with RA.

Corneal complications of rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) is an autoimmune disease that primarily affects the joints. Extra-articular manifestations (EAMs) are common and may affect up to 40.6% of patients. Ocular EAM can occur in 39% of the patients. The cornea is involved by different pathogenic mechanisms and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss. Severe corneal involvement is associated with increased mortality in RA patients. We aimed to review the prevalence, mechanisms, management and overall impact of corneal involvement in RA patients.

RECENT FINDINGS

Corneal involvement is frequent among RA patients. With the wider use of systemic immunosuppression, in particular the disease-modifying antirheumatic drugs (DMARDs), and with improvement of surgical techniques, spontaneous and surgery-related corneal ulceration and melting is becoming less common. However, RA patients are still at risk and should be carefully managed.

SUMMARY

RA-related corneal complications are associated with a decreased quality of life and poor ocular and systemic prognosis. Prompt recognition and a multidisciplinary approach involving topical ophthalmic management and systemic immunosuppression are the key factors to maintain ocular integrity and avoid a lethal outcome.

Safety of collagen cross linking in advanced keratoconus in a patient with scleroderma

A 26-year-old female presented to us with complaints of progressive loss of vision in right eye (RE) since past 6 months. Patient was a known case of generalized systemic sclerosis with hypothyroidism for the past 2 years and was under treatment with a rheumatologist Physical features of scleroderma seen in her included diffuse skin tightness, hyper pigmentation of skin of face, abdomen, thighs, legs and arms, with ulcers on fingers. Her best corrected visual acuity was 20/320 in the RE and 20/20 in the left eye (LE). Slit lamp examination showed Fleischer's ring in the RE cornea, and prominent corneal nerves in the LE cornea. Pentacam evaluation revealed advanced keratoconus in RE and Forme Fruste keratoconus in LE. Corneal ectasia in systemic sclerosis is a rare event. Collagen cross linking procedure when undertaken in auto immune disorders may cause adverse reactions. We present a case of systemic sclerosis with advanced keratoconus, who underwent uneventful collagen crosslinking procedure, with stabilization of the cornea post operatively, seen at 6 months follow up. In this case report we emphasize on the factors which need to be taken into consideration when planning for surgical management like collagen cross linking in a collagen vascular disease such as scleroderma.

Intracorneal scleral patch supported cyanoacrylate application for corneal perforations secondary to rheumatoid arthritis

Purpose:

To describe a new technique of intracorneal scleral patch (ICSP) supported cyanoacrylate tissue adhesive (CTA) application in corneal perforations, greater than 3.0 mm secondary to rheumatoid arthritis (RA).

Methods:

This Prospective, non-randomized, non-comparative, interventional series included 14 eyes (14 patients). All patients had corneal perforations sized 3.5 to 4.5 mm due to RA, which were treated with ICSP supported CTA application. A partial thickness scleral patch 1.0 mm larger than diameter of corneal perforation was prepared. A lamellar corneal pocket 0.5 mm all around the corneal perforation was created. The partial thickness scleral patch was placed in the corneal perforation site and the edge was fitted into the lamellar intracorneal pocket. A minimum quantity of CTA was applied on the scleral patch to seal the perforation.

Results:

The corneal perforations healed in 14 eyes (100%) in a mean 7.71 ± 1.14 (range, 6–9) weeks. One eye (7.14%) had inadvertent extrusion of ICSP due to premature removal of CTA but, Seidel's test was negative, and the corneal epithelial defect healed with BCL alone. One eye each (7.14%) developed steroid induced cataract and glaucoma. None of eyes developed infective keratitis, re-opening of corneal perforation (necessitating repeat procedure) or enlargement of corneal perforation requiring penetrating keratoplasty (PKP).

Conclusion:

ICSP supported CTA application is a successful alternative option to emergency PKP in treating corneal perforations sized 3.5 to 4.5 mm with associated RA.

Evaluation of corneal safety in systemic lupus erythematosus patients undergoing long-term hydroxychloroquine treatment

PURPOSE

The aim of this study was to examine the effects of long-term use of hydroxychloroquine (HQ) on the pachymetric, aberrometric, and densitometric values of the cornea and corneal endothelium in lupus patients.

METHOD

Twenty-two eyes (study group) of 22 patients using HQ for treatment of lupus and 25 eyes (control group) of 25 healthy individuals were included in this prospective study. A specular microscopy was used to measure corneal endothelial cell density (ECD), percentage of hexagonal cells (HEX%), coefficient of variation of the cell size (CV). Then, a Pentacam® HR corneal tomography system was used to measure central corneal thickness (CCT), corneal aberrometry values in 6-mm pupil diameters and corneal densitometry values in 6-mm corneal zones (0-2 mm and 2-6 mm).

RESULTS

While ECD was significantly lower in the study group than in the control group (p = 0.034), CCT was significantly higher in the study group (p = 0.032). The higher-order aberrations values and the anterior corneal densitometry values in the 0-2 mm and 2-6 mm corneal zones in the study group were found to be significantly higher than the control group (p = 0.021, p = 0.007 and p = 0.013).

CONCLUSION

Prolonged use of HQ may cause some changes in the cornea. In the follow-up of these cases, detailed examination of the cornea as well as the macula may be important for the protection of corneal health.

"Therapeutic Penetrating Keratoplasty: A Retrospective Review"

PURPOSE

To report the indications, outcomes, and complications of therapeutic penetrating keratoplasty (Th PK) in patients with corneal perforation and/or nonhealing corneal ulceration.

METHODS

A retrospective review was conducted of 51 eyes of 51 patients undergoing Th PK between January 1, 2006 and April 15, 2016. Data collected included patient demographics, visual acuity (VA), size of the corneal infiltrate and epithelial defect, degree of corneal thinning/perforation, microbiological results, surgical details, and postoperative complications.

RESULTS

The average age at presentation was 56.0 years (range 6-92 years), and most of the patients were females (n=31, 60.8%). Th PK was performed for corneal perforation in 28 eyes (54.9% of cases), nonhealing corneal ulcer in 16 eyes (31.4% of cases), and imminent risk of corneal perforation in 7 eyes (13.7% of cases). Infection was the most common reason for performing a Th PK and was present in 92.3% (47/51) of all cases. Of the infectious cases, the most common etiologies were bacterial (44.7%, 21/47) and fungal (31.9%, 15/47). The most common identifiable risk factor for undergoing a Th PK was a history of contact lens wear, which was seen in 32.7% of patients. Initial anatomic success was achieved in all patients after performing Th PK. Most patients (33/51; 64.7%) had clear grafts at their last follow-up examination. There was an improvement in VA in 70.2% (33/47, where data were available) of the patients at the final postoperative visit compared with the preoperative visit. Average best postoperative VA (1.14±0.88 logarithm of the minimum angle of resolution [LogMAR]; 20/276) was significantly better than the presenting (1.98±0.68 LogMAR; 20/1910) and preoperative (2.18±0.55 LogMAR; 20/3,027) visual acuities (P<0.0001). The most common complication after Th PK was cataract, which was present in 81.8% (27/33) of phakic eyes in which lens status could be assessed, followed by graft failure (47.1%; 24/51), and secondary glaucoma (45.1%; 23/51). Five eyes developed infection in the therapeutic graft, four eyes had persistent corneal epithelial defect at their last follow-up visit, and two eyes underwent evisceration.

CONCLUSIONS

Therapeutic penetrating keratoplasty achieves anatomic success and it is a useful procedure for restoring a stable cornea in cases in which infection fails to heal or when the cornea perforates. Furthermore, Th PK achieves corneal clarity and improves vision in most patients.