Background: Peripheral ulcerative keratitis (PUK) is a rare but severe ocular manifestation most commonly associated with rheumatoid arthritis amongst other autoimmune diseases. Quick diagnosis and co-management with corneal specialist and rheumatologist are crucial to preserve vision and life. A rare case of PUK associated with rheumatoid arthritis (RA) is presented with updates on current understanding and co-management of this condition.
Case Report: A 76 year-old Caucasian male presented to the eye clinic on a Friday as a new patient, with a chief complaint of a red right eye started two weeks ago and was treated with erythromycin ointment, but it got worse with moderate pain so he was referred over from the urgent care clinic. His BCVA OD, OS was 20/80 PHNI and PH20/25, respectively. Anterior segment evaluation showed severe conjunctival chemosis and injection, a superior temporal circular infiltrate and an inferior temporal linear infiltrate across the cornea with moderate corneal edema. Chart review confirmed the patient has been treated for rheumatoid arthritis with hydroxychloroquine and leflunomide for several years. The patient was diagnosed with PUK with mild scleritis associated with (RA) and initially treated with tobradex topical drops OD qid. His rheumatologist was contacted for co-management, and the patient was to return to clinic after the weekend. On the follow up visit, the patient felt better but the linear infiltrate persisted so oral prednisone 60mg/day was started with ofloxacin qid instead of Tobradex qid. The condition continued to improve over the next few follow up however the linear thinning of the cornea was not fully resolved so the patient was referred to a local corneal specialist. His rheumatologist continued to manage his RA closely and the patient confirmed that he was doing better overall at the latest visit.
Conclusion: In cases of PUK with stromal thinning and scleritis, autoimmune diseases such as RA and systemic lupus erythema often are the underlying systemic cause. Prompt diagnosis and co-management with other specialists are essential to minimize irreversible vision loss and save lives.
Koh LV, McChesney ME, Gosnell CE, Ngo RN. A Vision- and Life-threatening Case of Peripheral Ulcerative Keratitis. Optometric Clinical Practice. 2020; 2(1). doi: 10.37685/uiwlibraries.2575-77188.8.131.526. https://doi.org/10.37685/uiwlibraries.2575-77184.108.40.2066
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