Peripheral ulcerative keratitis in a patient with systemic-onset juvenile idiopathic arthritis

Peripheral ulcerative keratitis due to systemic diseases

PURPOSE OF REVIEW

To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases.

RECENT FINDINGS

Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death.

SUMMARY

Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.

Peripheral ulcerative keratitis: A review of aetiology and management

Background: Peripheral ulcerative keratitis (PUK) is a severe inflammatory disease of the peripheral cornea that can be caused by local factors or systemic inflammatory disease.Aim: The purpose of this review is to give an overview of the pathophysiology, aetiology, clinical features, diagnosis, and management of PUK.Method: A PubMed search was conducted using the keywords, ‘peripheral ulcerative keratitis’ and ‘Mooren’s ulcer’.Results: The peripheral cornea has unique characteristics the predispose to the development of PUK. These include fine capillary arcades that allow for deposition of immune complexes and subsequent activation of an inflammatory cascade with corneal melt. Several conditions have been implicated in the aetiology of PUK. The most commonly cited causes are rheumatoid arthritis (RA), granulomatosis with polyangiitis (GPA) and various dermatoses. In patients with RA, PUK usually presents in established disease, whereas in GPA, PUK may be the presenting feature in up to 60% of cases. In RA it heralds the onset of a systemic vasculitis with significant associated morbidity and mortality. The management of PUK follows an individualised stepwise approach. All patients require supportive measures to encourage healing and halt the process of keratolysis. Systemic autoimmune conditions need a systemic corticosteroid as a fast-acting agent to halt the inflammatory process while cytotoxic therapy maintains long term disease control. Failure to achieve disease control with CTT, necessitates the use of a biologic agent.Conclusion: Peripheral ulcerative keratitis is a severe inflammatory disease of the peripheral cornea that needs a thorough diagnostic workup and stepwise management approach.

Management of inflammatory corneal melt leading to central perforation in children: a retrospective study and review of literature

PURPOSE

To assess the outcome of early therapeutic penetrating keratoplasty (PKP) for corneal melt leading to perforation in children.

METHODS

Case notes of all the consecutive patients presenting with acute corneal perforation that underwent urgent therapeutic PKP between 2000 and 2010 to the practice of one of the authors, both NHS at Great Ormond Street Hospital for Children and private, were retrospectively reviewed. Onset of perforation, underlying cause, medical and surgical treatment, pre- and post-operative visual acuity, graft clarity, length of follow-up, and post-operative complications were recorded.

RESULTS

Four eyes of four consecutive patients (mean age of 9.5 years and median 8.5 years, range 4-17 years) were treated for acquired acute onset corneal perforations. There were three females and one male. Etiologies included herpes simplex keratitis secondary to immune recovery disease post bone marrow transplantation, acanthamoeba keratitis, recessive dystrophic epidermolysis bullosa, and blepharokeratoconjunctivitis with acne rosacea. Pre-operative visual acuity ranged from hand movements to 6/150. All the patients had severe anterior chamber inflammation. All eyes improved in visual acuity ranging from 6/9 to 6/18 with clear grafts at last follow-up. There was no recurrence of melt or perforation. Mean follow-up was 67 months (median 44 months).

CONCLUSION

PKP during the acute phase together with aggressive medical therapy and close follow-up may achieve good visual outcomes in children with corneal melt with perforation and should be considered. Waiting may sometimes allow the marked inflammatory response seen in children to cause irreversible structural and/or functional damage.

Partial and Total Descemet's Detachments in a Patient with Severe Terrien's Marginal Degeneration and Juvenile Idiopathic Arthritis

A 16-year-old female with juvenile idiopathic arthritis presented with a one-month history of decreasing vision and increasing corneal edema in her left eye. Slit-lamp examination, keratometric measurements, and OCT evaluation led to a diagnosis of Terrien's marginal degeneration in both eyes along with a complete detachment of Descemet's membrane in the left eye and partial detachment in the right eye. She was treated with an intracameral injection of air and then topical betamethasone and chloramphenicol which lead to the resolution of symptoms. We further examine the pathophysiology of this disease based on current literature.

Peripheral ulcerative keratitis in a child

Peripheral ulcerative keratitis is a destructive process involving perilimbal corneal inflammation and an overlying epithelial defect. It can be a manifestation of systemic autoimmune diseases or can be secondary to an infectious process. We present a case of a 7-year-old girl with peripheral ulcerative keratitis of unknown etiology. To the best of our knowledge, this is the first such case reported in a child.