Rheumatoid arthritis- associated corneal perforation Corneal perforation

Abstract

1) To describe the association between rheumatoid arthritis and corneal perforation.

2) To review the aetiology and management of rheumatoid arthritis -associated Peripheral ulcerative keratitis (PUK).

Patient and methods: A 35-year-old female presented with a five days history of decreased vision, pain, and watering and foreign body sensation in her left eye. She is a known case of Rheumatoid arthritis, which was quiescent at the time of presentation, and for which she is taking oral prednisolone, methotrexate, and etanercept and folic acid supplements. She never had any prior consultation with an ophthalmologist. The patients' visual outcomes and the development of any significant systemic complications were recorded. Slit-lamp examination in right eye showed mild meibomian gland dysfunction, central corneal thinning of about 60%, and also inferonasal thinning. Anterior chamber was of   normal depth.   Pupil was round and reacting, lens clear. Left eye had inferonasal corneal perforation, less than 2mm in maximum diameter, with iris prolapsed. There was no infiltration around the perforation and no corneal edema. Seidel test was positive in left eye. Corneal vascularization was noticed at 3’clock position.   Anterior chamber was shallow with inferior iridocorneal touch. Pupil was peaked inferiorly, lens being clear. Patient was admitted to ward started oral Carbonic anhydrase inhibitors, T. acetazolamide 250mg, four times per day for five days and artificial tears hourly. Perforation was sealed with cyanoacrylate glue with bandage contact lens. Patient was discharged after week.

Conclusion. 

PUK associated with rheumatoid arthritis often has a poor visual outcome and its appearance may herald the transformation of a patient's RA into the systemic vasculitic phase. RA-associated PUK should be managed with aggressive immunosuppression if the associated morbidity and mortality are to be avoided.