Infliximab for peripheral ulcerative keratitis treatment

Freeze-dried amniotic membrane graft with a spongy layer in bilateral peripheral ulcerative keratitis: a case report

BACKGROUND

Peripheral ulcerative keratitis (PUK) is a group of inflammatory corneal ulcers with stromal thinning and peripheral localization. Amniotic membranes (AM) are used for their anti-inflammatory and healing properties. A freeze-drying process now allows maintaining the AM viable for a long time at room temperature without altering its physical, biological, and morphologic characteristics. The effectiveness of spongy freeze-dried amniotic membrane (FD-AM) graft with multimodal imaging in the management of severe corneal thinning PUK has not been reported.

CASE PRESENTATION

A 67-year-old Caribbean man histologically diagnosed with ulcerative colitis, was referred to our tertiary eye care center for a deep nasal juxtalimbal ulcer of the left eye. He was treated with topical steroids and antibiotics, methylprednisolone pulses, and oral prednisone. Due to continuous stromal thinning with 100 μm of residual corneal thickness, the decision was made to perform surgery. Conjunctival resection, inlay and overlay spongy FD-AM (Visio Amtrix® S, Tissue Bank of France, FR) were performed to preserve globe integrity. Despite tapering off oral steroids, PUK developed in the fellow eye on the 2 months follow-up. Treatment with human monoclonal antibody against tumor necrosis factor-alpha was initiated to control the active underlying inflammation. Six months following surgery, the ulcer was healed and corneal thickness in front of the former ulceration was measured at 525 μm on anterior segment-optical coherence tomography. Confocal microscopy confirmed the integration of the amniotic membrane between the corneal epithelium and the anterior stroma.

CONCLUSION

Transplantation of FD-AM with a spongy layer was associated with restoration of normal corneal thickness in the PUK area. It seems to be a safe, effective, and easily accessible solution for the surgical management of PUK with impending perforation.

Baricitinib in severe and refractory peripheral ulcerative keratitis: a case report and literature review

Ocular disease, such as scleritis and peripheral ulcerative keratitis (PUK), may be a serious ocular complication. We present a patient with severe and refractory PUK treated with baricitinib. A review of the literature on Janus kinase inhibitors (JAKINIB) in refractory ocular surface pathology was also performed. For the literature review, the search in PubMed, Embase, and the Cochrane library was carried out from inception until 31 May 2021, including conference proceedings from four major rheumatology congresses. All original research articles studying JAKINIB treatment in patients with inflammatory eye disease were included. We present an 85-year-old woman with rheumatoid arthritis (RA) and secondary Sjögren's syndrome refractory to methotrexate, leflunomide, certolizumab pegol, adalimumab, and tocilizumab (TCZ). However, 10 months after starting TCZ, the patient suffered a perforation secondary to PUK, requiring urgent surgical intervention. In the absence of infection, she was treated with boluses of intravenous methylprednisolone followed by oral prednisone at high doses in a decreasing pattern together with baricitinib at a dose of 2 mg/day with a very rapid and persistent favorable response to eye and joint symptoms. After 18 months of treatment, the patient had not presented serious side effects or signs of reactivation of her disease. In addition to this report, three other studies including one PUK associated with RA and two non-infectious scleritis treated with tofacitinib were included in this literature review. All three patients had experienced an insufficient response to conventional treatment, including biologic agents, before being switched to JAKINIB, leading to a complete or partial recovery in all of them without significant adverse effects so far. JAKINIBs (baricitinib and tofacitinib) may be an effective and safe therapy in patients with severe autoimmune and refractory ocular surface pathology, such as scleritis and PUK.

Peripheral ulcerative keratitis, nodular episcleritis, and pulmonary nodules as the initial signs of rheumatic arthritis: A Case Report

Background

Rheumatoid vasculitis (RV) is a rare but potentially devastating complication of rheumatoid arthritis (RA). It typically occurs in patients with extra-articular manifestations. Here we reported a case of PUK with nodular episcleritis and pulmonary nodules that occurred in the same patient without joint involvement.

Case presentation

A 43-year-old Chinese woman, exhibited a partial crescent-shaped marginal corneal ulcer in the right eye at admission and the ulcer developed rapidly into nearly 360-degree ulcers in both eyes within one week. Nodular episcleritis was observed in the right eye. Conjunctival biopsy revealed vasculitis. Her rheumatoid factor (RF) and anti-cyclic citrullinated protein antibody were positive, while anti-neutrophilic cytoplasmic antibody (c-ANCA) and anti-protease 3 were negative. Pulmonary nodules were found, without joint involvement. The ocular condition did not relieve under the topical and systemic use of corticosteroids, or under other immunosuppressive agents until the infliximab therapy. PUK recurrence was observed after the discontinuation of infliximab.

Conclusions

Rapidly deteriorated PUK with nodular episcleritis and pulmonary nodules occurred in the same patient is a special case of RA without joint involvement. This case reinforces the concept that RV may be the initial sign of RA. Infliximab can be used to prevent further progress of RA-related PUK in some refractory cases.

The Complete Success in Refractory Mooren's Ulcer Treated with Infliximab

PURPOSE

To describe the management and outcome of two extremely rare and painful cases of Mooren's ulcer, an idiopathic peripheral autoimmune-associated ulcerative corneal disease.

METHODS

Case report with literature review on the management of ocular inflammation in Mooren's ulcer.

RESULTS

A 47-year-old female and a 76-year-old female presented with progressive bilateral Mooren's ulcer that were refractory to conventional immunosuppressive therapy. Following treatment with infliximab, an anti-tumor necrosis factor alpha, a significant improvement in disease progression was observed, with no corneal thinning or perforation at follow-ups.

CONCLUSION

This case report highlights how infliximab can be effective in cases with Mooren's ulcer refractory to conventional therapies.

Visual Outcomes of Patients With Peripheral Ulcerative Keratitis and the Effect of Immunosuppression-A 6-Year Experience in Queensland, Australia

OBJECTIVE

Peripheral ulcerative keratitis (PUK) can cause significant ocular morbidity and mortality. This study aimed to review the effects of systemic immunosuppression on visual outcomes.

METHODS

A state-wide, retrospective case series based in Queensland, Australia, was performed. A review of patients who presented with PUK to the major tertiary ophthalmology referral centers between January 2015 and January 2021 was undertaken. Parameters recorded included clinical features at presentation, investigations undertaken, treatment provided, visual outcomes, and mortality outcomes. The effect of immunomodulatory therapy on the change in vision from presentation to the most recent review was analyzed.

RESULTS

Twenty-two eyes of 26 patients with PUK (average age 69.81±14.54 years) were included and had a mean follow-up period of 577.73 days. Twelve patients (54.5%) had systemic autoimmune disease, one patient (4.5%) had positive syphilis serology, and nine patients (40.9%) had idiopathic PUK. Eighteen patients (81.8%) were treated with systemic steroids and 10 patients (45.5%) were treated with steroid-sparing immunomodulatory therapy. Average logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) at presentation and final follow-up were 0.63±0.65 and 0.64±0.82, respectively. Those who were treated with immunomodulatory therapy had a nonstatistically significant improvement in BCVA (-0.10±0.29 with vs. +0.10±0.35 without), and a similar trend was seen for doxycycline (-0.08±0.09 with vs. +0.22±0.49 without). Four of five perforations (80%) were surgically managed. Four patients (18.2%) were deceased.

CONCLUSIONS

Peripheral ulcerative keratitis poses significant clinical challenges and requires intensive medical treatment, frequently involving systemic immunomodulatory therapy. Surgical treatment is required in a significant minority of cases. Ocular management alongside the use of doxycycline and immunomodulatory therapy in consultation with specialist physicians can optimize visual and systemic outcomes.

ElSheikh R, Arabi A, R. Frank C, M. Elhusseiny A, K. Eleiwa T, Arami S, R. Djalilian A, Kheirkhah A. Peripheral Ulcerative Keratitis: A Review

Peripheral ulcerative keratitis (PUK) is a rare but serious ocular condition that is an important clinical entity due to its ophthalmological and systemic implications. It is characterized by progressive peripheral corneal stromal thinning with an associated epithelial defect and can be associated with an underlying local or systemic pro-inflammatory condition, or present in an idiopathic form (Mooren ulcer). Associated conditions include autoimmune diseases, systemic and ocular infections, dermatologic diseases, and ocular surgery. Cell-mediated and auto-antibody-mediated immune responses have been implicated in the pathogenesis of PUK, destroying peripheral corneal tissue via matrix metalloproteinases. Clinically, patients with PUK present with painful vision loss, a peripheral corneal ulcer, and often adjacent scleritis, episcleritis, iritis, or conjunctivitis. Diagnostic evaluation should be focused on identifying the underlying etiology and ruling out conditions that may mimic PUK, including marginal keratitis and Terrien marginal degeneration. Treatment should be focused on reducing local disease burden with topical lubrication, while simultaneously addressing the underlying cause with antimicrobials or anti-inflammatory when appropriate. Existing and emerging biologic immunomodulatory therapies have proven useful in PUK due to autoimmune conditions. Surgical treatment is generally reserved for cases of severe thinning or corneal perforation.

Peripheral Ulcerative Keratitis Secondary to the Inactive COVID-19 Vaccine-CoronaVac

PURPOSE

To report a case of peripheral ulcerative keratitis (PUK) secondary to the inactive Covid-19 vaccine.

METHODS

The case of a 67-year-old man who presented with unilateral progressive vision-threatening PUK with nodular scleritis was reported. The results of clinical examinations with surgical and medical treatments were noted.

RESULTS

The extended workup for autoimmune and infectious etiologies for PUK that all returned negative. The patient was treated with oral steroids, azathioprine, and topical cyclosporine with topical dexamethasone for his PUK and underlying possible immunopathology. Corneal amniotic membrane grafting was also performed 4 times and finally, the patient underwent penetrant keratoplasty for visual rehabilitation.

CONCLUSIONS

To our knowledge, we report the first case of PUK that is possible to secondary to an inactive vaccine for SARS-CoV-2. The inactive covid vaccine should be considered as an etiological agent in PUK cases where the standard workup is negative.

Peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.

Anterior segment optical coherence tomography imaging in peripheral ulcerative keratitis, a corneal structural description

Background

Anterior segment optical coherence tomography (AS OCT) is a helpful tool used to diagnose and manage many corneal conditions, but its use has not been reported in case of peripheral ulcerative keratitis (PUK). The aim of this study is to describe AS OCT findings in cases of PUK.

Methods

Retrospective observational case series of six eyes presenting with a PUK and proven systemic vasculitis. Clinical course, slit lamp photographs, and AS OCT findings were the main outcomes.

Results

The AS OCT findings were found to correlate with the ocular disease’s level of activity. In the acute stage, an absence of corneal epithelium, a scrambled appearance of the anterior stroma and a heterogeneous stromal reflectivity were observed. During the reduction of disease level activity, an irregular hyporeflective epithelium, a smoother anterior stroma, and a homogenous hyperreflective stroma were seen. At the healed stage, a filling of the corneal defect by a hyporeflective thick epithelium, the persistence of the hyperreflective underlying stroma, and a demarcation line were observed. The mean total corneal thickness at last follow-up was significantly thicker (509 ± 147 μm) compared with the mean corneal thickness at onset (408 ± 131 μm; P = 0.03).

Conclusions

AS OCT provides an assessment of structural changes occurring in PUK, useful for its diagnosis and monitoring.

Ocular Manifestations of Rheumatoid Arthritis: Implications of Recent Clinical Trials

While rheumatoid arthritis (RA) typically presents with synovitis of the small and medium joints of the hands, ocular manifestations of the disease are generally overlooked and largely underdiagnosed. These complications usually present in longstanding RA population and occasionally represents the first manifestation of the disease and generally affect the anterior chamber of the eye, leading to keratoconjunctivitis sicca, episcleritis, scleritis, peripheral ulcerative keratitis and anterior uveitis. In this review, we present the current understanding of the pathophysiologic mechanisms for ocular disease in RA, including the role of oxidative stress, cytokine imbalance, chronic inflammation, vascular permeability, immune complex deposition and the role of T-cells as well as the contribution of tear hyperosmolarity among other factors. We also discuss the clinical presentation and diagnosis of each of the ocular disease entities highlighting the latest strategies in the management of this serious disorders that could potentially lead to blindness and the implications of recently completed and ongoing clinical trials in the field. While RA disease control is the cornerstone in the management of RA-associated ocular manifestations, early recognition of ocular pathology with prompt referral to ophthalmology is of paramount importance in order to prevent blindness and improve the quality of life in this patient population.

Tumor necrosis factor alpha in sleep regulation

This review details tumor necrosis factor alpha (TNF) biology and its role in sleep, and describes how TNF medications influence sleep/wake activity. Substantial evidence from healthy young animals indicates acute enhancement or inhibition of endogenous brain TNF respectively promotes and inhibits sleep. In contrast, the role of TNF in sleep in most human studies involves pathological conditions associated with chronic elevations of systemic TNF and disrupted sleep. Normalization of TNF levels in such patients improves sleep. A few studies involving normal healthy humans and their TNF levels and sleep are consistent with the animal studies but are necessarily more limited in scope. TNF can act on established sleep regulatory circuits to promote sleep and on the cortex within small networks, such as cortical columns, to induce sleep-like states. TNF affects multiple synaptic functions, e.g., its role in synaptic scaling is firmly established. The TNF-plasticity actions, like its role in sleep, can be local network events suggesting that sleep and plasticity share biochemical regulatory mechanisms and thus may be inseparable from each other. We conclude that TNF is involved in sleep regulation acting within an extensive tightly orchestrated biochemical network to niche-adapt sleep in health and disease.

Peripheral Ulcerative Keratitis Associated with Autoimmune Disease: Pathogenesis and Treatment

Peripheral ulcerative keratitis (PUK) is type of crescent-shaped inflammatory damage that occurs in the limbal region of the cornea. PUK is always combined with an epithelial defect and the destruction of the peripheral corneal stroma. PUK may have a connection to systemic conditions, such as long-standing rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Wegener granulomatosis (WG), relapsing polychondritis, classic polyarteritis nodosa and its variants, microscopic polyangiitis, and Churg-Strauss syndrome. However, the most common connection is with RA, which is also the focus of this review. The pathogenesis of PUK is still unclear. It is thought that circulating immune complexes and cytokines exert an important influence on the progression of this syndrome. Treatment is applied to inhibit certain aspects of PUK pathogenesis.