Recurrent Corneal Perforation Secondary to Rheumatoid Arthritis–Related Dry Eye
To highlight the importance of the combined judgment and decision between ophthalmologists and rheumatologists in managing ocular complications of collagen vascular diseases.
Forty-seven years old Saudi lady known case of clinically stable rheumatoid arthritis for the last 8 years presented to emergency department on October 2009 complaining of sudden reduction of vision in the left eye with pain. Ocular examination revealed left central corneal perforation secondary to sever dry eye (Schirmer’s test is less than 2mm in 5min)
Emergency penetrating keratoplasty(PKP) and punctual occlusion were performed for the left eye which had longer healing time which was managed by amniotic membrane transplantation (AMT) one month later. Rheumatology consultation revealed that the case is clinically stable and medications adjustment is not needed. On January 2010, the patient presented to our service with recurrent graft perforation in the left eye. Therefore, PKP and AMT were done. On May 2010, she presented with the 3rd left corneal perforation and melting which was managed by PKP and AMT. Postoperatively, the rheumatologist decided to start her on Infliximab. Postoperatively, the left corneal graft showed stable course with no perforation or melt. Last ocular exam of the left eye on June 2014 showed unaided visual acuity of 6/24, moderate SPK, mild anterior corneal haze.
This case reveals the importance of adjustment of systemic immunosuppressive agents according to the severity of dry eye even if the other clinical findings are stable. infliximab may prove to be the optimal treatment option in refractory cases of RA associated dry eye.