Ulceration of the cornea in rheumatoid arthritis

Sutureless "Contact Lens Sandwich" Technique for Amniotic Membrane Therapy of Central Corneal Ulcers

PURPOSE

To describe a new technique for sutureless and glue-free amniotic membrane transplantation (AMT) and to investigate its effectiveness to treat corneal persistent epithelial defects (PEDs), compared to bandage contact lens (BCL) application alone.

METHODS

We performed AMT with "contact lens sandwich technique" (CLS-AMT) in 8 consecutive patients with central/para-central (up to 4.00 mm from the geometrical centre) PED/ulceration and we retrospectively compared the results with 11 BCL procedures.

RESULTS

The procedures were performed successfully with no complications.CLS-AMT showed significantly shorter healing time than BCL (24.0  ±  19.1 vs 42.9  ±  14.6 days; P < 0.05, Mann-Whitney test). Recurrence rates were 12% and 27% for CLS-AMT and BCL, respectively.

CONCLUSION

CLS-AMT technique, based on the suction effect due to the superposition of a bandage contact lens on the AM-ring complex, represents a quick, low cost, easy to perform and nearly non-invasive AMT technique. This approach is able to provide adequate fixation of AM, and it seems to be a safe and effective treatment for patients with PEDs.

Cellular Infiltrate in Rheumatoid Arthritis-associated Paracentral Corneal Ulceration

PURPOSE

To investigate an immunopathogenesis of central and paracentral corneal ulceration associated with rheumatoid arthritis.

METHODS

Sparse infiltrating cells in the ulcer area were identified by immunohistochemistry applied to archived formalin fixed, paraffin embedded tissues that had been recovered from patients undergoing penetrating keratoplasty necessitated by rheumatoid-associated central or paracentral corneal ulceration.

RESULTS

Clinically, the ulcers presented as non-infiltrated lesions with a modicum of other ocular inflammation. Sparse T-lymphocytes were consistently identified in the subepithelial areas adjacent to the ulcer, with some neutrophils and macrophages in the stroma. B-lymphocytes were not detected. MHC Class II antigens reactivity was noted on some infiltrating cells and on corneal endothelium of two specimens.

CONCLUSIONS

Immunohistochemistry of archival tissue facilitated detection and identification of sparse infiltrate in this infrequent corneal melting. Selective, consistent finding of T-lymphocyte infiltration in the ulcer area supports an immunopathogenesis of this clinical entity.

Rheumatoid arthritis-associated corneal ulceration complicated by bacterial infection

We report two cases of rheumatoid ocular disease complicated by infection of methicillin-sensitive Staphylococcus aureus (MSSA) in one case, and methicillin-resistant Staphylococcus aureus (MRSA) in the other. In both cases, punctal occlusion and immunosuppressive therapy were presumed to be major risk factors of the infections. In addition, the characteristic feature was corneal melting, which is probably accelerated by infection. To avoid infectious progression and melting, potent antibiotics followed by immunosuppressive therapy were necessary.

High expression of interleukin-1beta in the corneal epithelium of MRL/lpr mice is under the control of their genetic background

MRL/Mp mice bearing the Fas deletion mutant gene, lpr (MRL/lpr), spontaneously develop polyarthritis, sialoadenitis and dacryoadenitis, resembling rheumatoid arthritis (RA), and also corneal involvement such as keratopathy and scleritis, which is a major complication in RA patients. In this study, we found that the expression levels of IL-1beta and MMP-1 mRNAs in cornea were high in both MRL/lpr and MRL/Mp-+/+ strains of mice at an age younger than when they develop any inflammatory lesions. This was not true of other inbred strains, even those bearing the lpr gene, and also not of (NZB x NZW) F1 lupus mice. There was no significant difference in the expression of IL-1alpha and TGFbeta in cornea in these strains. Using crosses between MRL/lpr and C3H/HeJ-lpr/lpr (C3H/lpr) mice, at least the expression of IL-1beta was found to be under the control of the MRL genetic background, likely with a recessive mode of inheritance. Considering that IL-1beta in cornea was detected particularly in the epithelial layer, the high expression of IL-1beta in cornea is most likely involved in the genetic predisposition for corneal involvement and possibly also for arthritis in an MRL strain of mice.

Nontraumatic corneal perforation

PURPOSE

To study the predisposing conditions, treatments, and visual outcomes of nontraumatic corneal perforations.

METHODS

A retrospective chart review was conducted of all nontraumatic corneal perforations seen between January 1992 and December 1998, with > or = 3 months of follow-up, at the Cornea Service Wills Eye Hospital.

RESULTS

A total of 40 nontraumatic corneal perforations was analyzed. Sixty-two percent of the cases were female. At presentation, 35 of 40 eyes (87.5%) had best corrected visual acuity of 20/200 or worse. The most common diseases associated with perforations were keratoconjunctivitis sicca (12 eyes, 30%), bacterial keratitis (6 eyes, 15%), exposure keratopathy (5 eyes, 12.5%), and herpes simplex virus (HSV) keratitis (4 eyes, 10%). Visual acuity improved > or = 2 Snellen lines in 3 of 8 eyes (37.5%) treated with penetrating keratoplasty, 5 of 14 eyes (35.7%) treated with tissue adhesive, and 1 of 12 eyes (8.3%) given medical treatment. After allowing for the different levels of presenting vision, treatment modality was not significantly related to final visual outcome.

CONCLUSION

Keratoconjunctivitis sicca is the most common underlying disease associated with nontraumatic corneal perforation. Corneal perforations were managed successfully using tissue adhesive, medical therapy, or penetrating keratoplasty. Treatment depended on the characteristics of the perforation and on the visual potential of the eye.

Topical cyclosporin stimulates neovascularization in resolving sterile rheumatoid central corneal ulcers

OBJECTIVE

To report the successful use of topical cyclosporin for treatment of central sterile corneal ulcers associated with rheumatoid disease.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS/INTERVENTION

Five patients (7 eyes) with collagen vascular disorders presented with central, sterile corneal ulcers. An extensive medical evaluation did not reveal active underlying rheumatoid disease in any patient. Inadequate clinical response with use of topical steroids and lubricants led to corneal perforations requiring multiple tectonic procedures. Systemic immunosuppressive therapy either could not be initiated owing to a systemic contraindication or was discontinued owing to intolerance and side effects. The patients were ultimately treated with topical cyclosporin.

RESULTS

Six of the 7 eyes responded favorably. An intense limbal vascularization began within 48 hours of treatment. The neovascularization progressed centrally with the simultaneous arresting of epithelial and stromal ulceration. Over a 2-week period, re-epithelization occurred with vascularization proceeding throughout the cornea. After several months, the corneal vessels attenuated, and all signs of inflammation subsided. Intrastromal bleeding with corneal blood staining occurred in 1 patient; this resolved over several months. No recurrences of corneal ulceration occurred in a mean follow-up period of 28 months (range, 7 to 60 months). None of the 5 patients have had a reactivation of their rheumatoid disease in the follow-up period.

CONCLUSION

The clinical response in these patients contrasts with previous animal studies demonstrating an anti-angiogenic property of cyclosporin. We report that an immediate intense neovascularization is the first sign of a favorable clinical response. Treatment with topical cyclosporin alone may be considered in patients with sterile corneal ulcers associated with rheumatoid disease in the absence of systemic activation.

The peripheral corneal melting syndrome and psoriasis: coincidence or association?

The peripheral corneal melting syndrome (PCMS) is a rare disease consisting of marginal corneal thinning that can progress to perforation. The PCMS carries a grave prognosis and it is of vital importance that dermatologists are aware that this may be responsible for a painful red eye in a patient with psoriasis. We highlight the features of the PCMS developing in an elderly woman with long-standing psoriasis to increase awareness of its significance, and hypothesize that an association may exist between the two conditions. Only one previous report has been published in which the authors speculate on the possible association of this syndrome with psoriasis. That few other cases have been described is either a consequence of under-reporting by both ophthalmologists and dermatologists unaware of a link or because the relationship between the syndrome and psoriasis is genuinely coincidental.

Incidence of ocular complications in rheumatoid arthritis and the relation of keratoconjunctivitis sicca with its systemic activity

To investigate the incidence of ocular complications in patients with rheumatoid arthritis under modern modalities of treatment and find the relationship between its systemic activity and ocular complications, routine ophthalmological examinations were done as a prospective study in 111 consecutive patients including 89 inpatients and 22 outpatients with rheumatoid arthritis seen from April to May 1995, in a hospital with a special clinic for rheumatology. Keratoconjunctivitis sicca (secondary Sjögren's syndrome) was found in 19 patients (17.1%), scleritis in one patient (0.9%), central retinal vein occlusion in 2 patients (1.8%), and idiopathic retinal hemorrhage in 3 patients (2.7%). Patients with keratoconjunctivitis sicca had significantly higher titers of rheumatoid factor (Mann-Whitney's U-test, p = 0.0048), higher levels of IgM (p = 0.0484), and lower levels of HDL-cholesterol (p = 0.0191), compared to patients without it. The incidence of ocular complications was comparable to the previous studies and keratoconjunctivitis sicca should be considered in patients with high titers of rheumatoid factor.

Ocular complications of adult rheumatoid arthritis

In a prospective study of 325 patients with adult rheumatoid arthritis, ocular complications were seen in 73 patients (22.4%). Keratoconjunctivitis sicca was the most common ocular lesion. Other lesions were episcleritis, scleritis, marginal thinning of the cornea with keratolysis, stromal corneal opacities with peripheral vascularisation, and iridocyclitis. The mean duration of the arthritis and the mean duration of seropositivity were found to be significantly higher in patients with ocular complications. Physicians should include ophthalmic examination as a routine in their protocol for patients with rheumatoid arthritis to facilitate early diagnosis and treatment of ocular complications.

Collagenase (MMP-1) and TIMP-1 in destructive corneal disease associated with rheumatoid arthritis

The aim of the study was to immunolocalise interstitial collagenase (MMP-1) and the tissue inhibitor of metalloproteinases (TIMP-1) in ulcerating corneas from patients with rheumatoid arthritis, to determine whether changes in expression are associated with destructive corneal disease. Collagenase was expressed by stromal cells in 8 of 8 ulcerating corneas but was not seen in normal tissue (n = 3). TIMP-1 was abundant throughout the normal stroma, but was much reduced or absent from diseased corneas. Collagenase staining was frequently more intense near the epithelial surface and associated with a cellular infiltrate consisting of activated antigen-presenting cells (HLA-DR+), many of which were macrophages (CD68+) and derived from the epithelium or limbus (S100+). Interstitial collagenase produced by infiltrating macrophages and/or stimulated corneal fibrocytes is probably a major mediator of collagen degradation in rheumatoid corneal ulceration. In addition, reduced levels of TIMP-1 expression are consistent with collagenase activity and tissue destruction. Epithelial-stromal cell interactions and the production of local inflammatory mediators are of major importance in the pathogenesis of corneal destruction, although the precise nature of the antigenic stimulation and/or cellular interactions remains to be elucidated.

Prevention of immune-mediated corneal graft destruction with the anti-lymphocyte monoclonal antibody, CAMPATH-1H

We report a patient with peripheral rheumatoid corneal melting who developed a corneal perforation in one eye requiring tectonic keratoplasty. Nine consecutive corneal grafts were rapidly destroyed despite systemic immunosuppression with corticosteroid, cyclophosphamide, azathioprine and cyclosporin A. A rejection episode was observed in one graft before it melted and allograft rejection may have contributed to the destruction of other grafts. Corneal graft survival was ultimately achieved by systemic immunosuppression with the anti-lymphocyte monoclonal antibody, CAMPATH-1H. A single episode of rejection developed in the early post-operative period which was easily reversed by topical corticosteroid. Corneal melting has not recurred and the graft has now remained intact and clear for 24 months. Anti-lymphocyte monoclonal antibodies may therefore provide effective immunosuppression in the treatment of refractory ocular disorders.

Lamellar keratoplasty in the management of inflammatory corneal ulceration and perforation

Corneal ulceration and perforation may occur in the course of several systemic and ocular inflammatory conditions. These serious complications may respond to systemic immunosuppression and conjunctival surgery, but tectonic keratoplasty is sometimes required. We report on 10 cases of corneal ulceration (of which 8 suffered perforation) in patients with rheumatoid arthritis, Stevens-Johnson syndrome and Mooren's ulceration which were treated by lamellar keratoplasty. Our microsurgical technique for lamellar keratoplasty benefited from the use of viscoelastic agents, cyanoacrylate adhesive and an adjustable stepped diamond knife. These recent advances have made this procedure as easy to perform as a penetrating keratoplasty. Lamellar keratoplasty virtually eliminates the risk of graft rejection and reduces the risk of perforation in the event of a subsequent exacerbation of the melting process. Surgery preserved the globe in all 10 cases, and the pre-operative visual acuity was maintained or improved in all but 1 case. Six patients achieved a visual acuity of 6/60 or better. Concomitant systemic immunosuppression was used in 6 cases and a subsequent penetrating keratoplasty performed in 3 cases. Lamellar keratoplasty provides a valuable method of preserving the integrity of the globe and maintaining useful vision in these difficult cases.

Paracentral rheumatoid corneal ulceration. Clinical features and cyclosporine therapy

Six patients with rheumatoid arthritis (eight eyes) presented with small paracentral perforating corneal ulcers in otherwise quiet eyes. Initial management in five patients (seven eyes) consisted of systemic immunosuppression and therapeutic tissue adhesive with a bandage contact lens or tectonic keratoplasty. Ulceration recurred in all of these eyes, and recurrent ulcers treated with repeat tectonic keratoplasty or therapeutic tissue adhesive and a bandage contact lens all developed recurrent ulceration. The introduction of topical cyclosporine therapy in five eyes with recurrent corneal ulceration was associated with arrest of keratolysis and rapid re-epithelialization of the ulcer in all cases. One corneal ulcer was successfully treated initially with topical cyclosporine, tissue adhesive, and a bandage contact lens. In patients with rheumatoid arthritis and small paracentral corneal ulcerations or perforations, application of tissue adhesive and a bandage contact lens and introduction of topical cyclosporine may be the preferred initial treatment.

Corneal-scleral melt in association with cataract surgery and intraocular lenses: a report of four cases

Four patients with rheumatoid arthritis had cataract extraction with implantation of an intraocular lens (IOL). Postoperatively three patients developed progressive scleromalacia perforans. All three cases required patch grafting of the sclera and two of them developed progressive melting of the sclera and graft. The fourth case involved progressive corneal melting with extrusion of the IOL despite treatment with penetrating keratoplasties. All four cases developed retinal detachments with loss of vision and three of the eyes were subsequently enucleated. We describe each case and discuss the clinicopathologic correlations of this condition. The need for careful evaluation of rheumatoid arthritis patients with cataract surgery and IOL implantation is emphasized.

Management of noninfectious corneal ulcers

Noninfectious corneal ulcers can occur as an isolated ocular problem (e.g., sequela of eye injury, Mooren's ulcer) or they may be associated with various collagen vascular or other autoimmune diseases, sometimes being the presenting sign of the disease. Conditions that affect the integrity of the ocular surface epithelium (exposure keratitis, neurotrophic keratitis, keratomalacia, recurrent corneal erosions) may also lead to development of sterile corneal ulcers. Rarely, these ulcers occur as a complication following cataract surgery. With recent advances in the understanding of the causes and pathophysiology of corneal melting, rapid and effective medical and surgical treatment is often able to halt relentless destruction of the cornea. Since treatment varies vastly depending on the underlying cause of the ulceration, prompt and accurate diagnosis is of critical importance. This review presents guidelines for the diagnosis of corneal ulcers, and a stepwise approach to their medical and surgical treatment.

Peripheral corneal disorders

The peripheral cornea is anatomically and physiologically distinct from its central counterpart. The major differences relate to the gradual transition of corneal tissues to those of the conjunctiva, episclera, and sclera; furthermore, the vascular structures, lymphatics, and inflammatory cells from these neighboring structures are intimately associated with the limbus and periphery of the cornea. The peripheral cornea is thereby predisposed to three main classes of disorders which do not normally involve the central cornea. First, local conditions affecting the sclera and conjunctiva may secondarily spread to involve the limbus and peripheral cornea. These include several infectious diseases, as well as hypersensitivity conditions, mass lesions, and degenerations. Second, due to the associated blood vessels and lymphatics, the peripheral cornea may be involved in a variety of systemic diseases, including vasculitides, autoimmune disorders, and abnormal metabolic conditions. Finally, there are several conditions, such as the noninflammatory peripheral degenerations, which primarily affect the peripheral cornea without associated ocular or systemic changes. In this review, we present a classification and discussion of the various disorders which may involve the peripheral cornea.

Rheumatoid arthritis: clinical features and pathogenetic mechanisms

Rheumatoid arthritis is a disorder characterized by chronic inflammation affecting predominantly articular tissues, leading in some instances to disruption of the normal structure and function of the joint. In some patients extra-articular manifestations are also present. In the joints, the pathologic lesion consists of synovial cell proliferation with infiltration by inflammatory cells. The complex interaction among these cells is likely responsible for the connective tissue abnormalities that characterize the rheumatoid lesion. The factors responsible for inducing the inflammatory process are unknown.

Rheumatoid arthritis and sterile corneal ulceration. Analysis of tissue immune effector cells and ocular epithelial antigens using monoclonal antibodies

Tissue immune effector cells and epithelial surface antigens present in eye tissue of rheumatoid arthritis (RA) patients with sterile corneal ulceration were studied using a large panel of monoclonal antibodies. During periods of active corneal ulceration, conjunctivae and corneas of all RA patients studied contained numerous immune-associated (Ia) antigen-positive tissue macrophages. In 4 of 6 patients, conjunctival or corneal T cell infiltrations were present. In 2 patients, a T cell vasculitis was seen in conjunctival tissue. Conjunctival epithelial cells of all 6 RA patients expressed Ia antigens during active corneal ulceration. These data provide evidence for immune-mediated mechanisms in the pathophysiology of corneal ulceration in RA. Moreover, the expression of Ia antigens by conjunctival epithelial cells may be a useful indicator of disease activity in RA patients with sterile corneal ulceration.

Conjunctival resection for the treatment of the rheumatoid corneal ulceration

Conjunctival resection is an effective therapeutic modality for the treatment of a marginal furrow associated with rheumatoid arthritis. Rapid reepithelialization was observed following this procedure for the treatment of five such stromal ulcers that occurred in three rheumatoid patients. Keratoconjunctivitis sicca was diagnosed in two of these patients. In four of five ulcers, minimal healing resulted from a prior trial of patching. Conjunctival resection was performed as the primary therapeutic procedure in one case in which perforation seemed possible. A literature review uncovered an additional nine such ulcers in six rheumatoid patients treated by conjunctival resection. In each case corneal healing was observed soon after the procedure. No recurrences were reported on 4- to 24-month follow-ups. This procedure has proven to be effective in each of our rheumatoid corneal ulcers and in each of the case reports in the literature. It would appear to work more reliably than subconjunctival heparin, topical anticollagenases, or immunosuppression. Conjunctival resection is a simple minor room procedure performed under topical anesthesia. It carries minimal risk for the patient. The early use of this technique for rheumatoid stromal ulcers is advocated, especially when the area of ulceration is extensive, when the stromal loss is progressive, and when stromal reserve is minimal. Early conjunctival resection can shorten the hospital stay, and in more severe cases could prevent perforation. Based on successful treatment in a combined total of 14 peripheral rheumatoid corneal ulcerations, the authors believe conjunctival resection should have a more prominent place in the treatment of this condition.

Peripheral corneal melting syndrome in association with psoriasis: a report of two cases

Images

Peripheral rheumatoid ulceration and evidence for conjunctival collagenase production

Two patients with rheumatoid arthritis and peripheral corneal ulcerations were successfully treated by conjunctival resection. The tissues removed were assayed by a variation of the radial diffusion method for tissue collagenases. We used an agarose matrix containing lathyritic rat skin collagen. Wells 3 mm deep were punched in the agarose-collagen and surgical specimens were placed in the wells. Spaces remaining in the wells were filled with balanced salt solution. The assay dishes were incubated for four days at 32 degrees C near 100% humidity. Under these conditions release of collagenase was detected by the clearing of diffuse zones in the gel surrounding the well. Conjunctiva proximal to the ulcer produced definite zones of lysis, whereas control specimens taken remote to the ulceration produced no lysis. This direct evidence for collagenase involvement offers an exploration for the beneficial effects of conjunctival resection.