Peripheral Keratitis Research Articles

Different modalities for management of peripheral corneal ulcer

Background The peripheral cornea has unique features, which make it more vulnerable to inflammatory reactions and necrosis. Peripheral corneal ulcer is caused by various infectious and noninfectious ocular and systemic diseases. It may impair vision by inducing astigmatism and ulcer progression to the center or threaten the eyeball integrity by spontaneous perforation. So, early diagnosis and proper treatment prevent blindness. Aim To evaluate different modalities for management of peripheral corneal ulcer. Patients and methods In this prospective study, 30 eyes of 29 patients having peripheral corneal ulcer were evaluated and treated with medical treatment and surgical intervention as adjunctive therapy in resistant cases. The duration of the study was 6 months with a follow-up period of 3 months. Results Of 30 eyes, 14 responded to medical treatment, with complete epithelial healing ranging from 2 to 6 weeks, with a mean of 3.36 ± 1.34 weeks. On the contrary, 16 of 30 eyes were resistant within 2 weeks and underwent surgical interference. A total of seven eyes were managed by amniotic membrane transplantation, and nine eyes were treated with tectonic keratoplasty. Time of healing ranged from 4 to 14 weeks, with a mean of 9.38 ± 3.91. All eyes showed anatomically successful outcomes. Conclusion Mild infectious peripheral keratitis heals on medical treatment. Cases of moderate infectious peripheral keratitis with history of diabetes mellitus or exposure keratitis need amniotic membrane transplantation as adjunctive therapy. Severe noninfectious cases with history of rheumatoid arthritis or Mooren’s ulcer need systemic treatment and tectonic keratoplasty.

Presumed tuberculosis-related scleritis

AimsTo evaluate the clinical characteristics and therapeutic outcome of patients with recurrent scleritis of unknown demonstrable aetiology and positive QuantiFERON-TB Gold In-Tube test (QFT).MethodsRetrospective chart review of the demographic, clinical,...

Ocular rosacea and corneal perforation: A rare case report

Acne rosacea is a chronic skin condition with exacerbations and remissions, which requires long-term therapy to maintain symptomatic control. Etiology of rosacea is not fully understood and more than 50% of patients with rosacea have ocular manifestations such as blepharitis, conjunctival hyperemia, and rosacea-associated keratitis. Sight-threatening disease is rare with rosacea; however, keratitis can result in corneal ulceration and eventual perforation if not treated aggressively. Here, in my case, there is acne rosacea associated with blepharitis, dryness, peripheral keratitis, and eventually landed up with corneal perforation which then managed with corneal grafting.

Delayed-onset Bilateral Peripheral Posterior Interstitial Keratitis Associated with Epstein-Barr Virus-Induced Infectious Mononucleosis

ABSTRACT Introduction Epstein-Barr Virus (EBV) has been previously reported to cause rare occurrence of mostly epithelial and nummular keratitis. We hereby report two patients developing bilateral peripheral deep interstitial keratitis following EBV-related infectious mononucleosis (IM). Description of cases Two female adolescents presented with findings of chronic relapsing posterior interstitial keratitis with neovascularisation mostly located in the superior and inferior peripheral cornea, in absence of signs of anterior uveitis. The disease presented months after the occurrence of IM. Other etiologies of interstitial keratitis were excluded. EBV DNA could not be detected in the aqueous humor of both patients. The patients responded promptly to topical corticosteroids, with multiple recurrences reported in one case. Conclusion EBV-induced IM can cause bilateral peripheral interstitial keratitis with delayed onset. Progressive relapsing course of the keratitis can be observed.

Presumed tuberculous sclerokeratouveitis in immunocompetent South African patients.

Ocular tuberculosis remains a diagnostic challenge since its clinical presentation is so variable. We describe the clinical characteristics of patients presenting with sclerokeratouveitis secondary to presumed Mycobacterium tuberculosis infection. Retrospective analysis of 14 patients presenting with sclerokeratouveitis to Tygerberg Hospital. All patients underwent: (1) detailed ophthalmological evaluation, (2) tuberculin skin test (TST), (3) chest X-ray to assess for systemic disease, and (4) laboratory investigations to exclude other causes of ocular inflammation. Tuberculous sclerokeratouveitis was diagnosed if: (1) clinical findings showed scleritis with adjacent peripheral keratitis and anterior uveitis, (2) TST was positive, (3) other causes of sclerokeratouveitis were excluded, and (4) positive response to tuberculosis treatment without adjunctive anti-inflammatory agents was noted. Seventeen eyes were included. Mean age was 29.1 ± 12.1 years. All patients were females with no history of previous/current pulmonary tuberculosis. Only one patient was HIV positive, but virologically suppressed. All patients had a strongly positive TST result. Scleral involvement was nodular in four patients and diffuse in ten. Corneal involvement manifested as ill-defined peripheral stromal opacities adjacent to the area of scleritis with deep corneal stromal vessels. Corneal sensation was decreased in all involved eyes. All patients responded to tuberculosis treatment with complete resolution of the sclerokeratouveitis. In our highly endemic area, tuberculous sclerokeratouveitis is seen in young, immunocompetent patients, and responds well to tuberculosis treatment without concurrent immunosuppression. Decreased corneal sensation may lead to an incorrect diagnosis of herpetic infection if a high index of suspicion is not maintained for ocular tuberculosis.

ПАТОЛОГИЧЕСКИЕ ПЕРЕЛОМЫ ЛУЧЕВЫХ КОСТЕЙ У БОЛЬНОЙ С АУТОИММУННЫМ ПОЛИГЛАНДУЛЯРНЫМ СИНДРОМОМ 1-ГО ТИПА

The author observed 1 patient with APGS-1 type. The disease was manifested by autoimmune damage of peripheral glands (hypoparathyroidism, adrenal insufficiency, hypothyroidism, hypogonadism), destructive keratitis and candidiasis. With a minor injury, pathological fractures of radial bones in the lower third of the forearm have been reported over last 14 years. Within a year, it was not possible to consolidate these fractures completely. The author suggests that the the diversity of the signs can be explained only by the presence of another genetic disease - imperfect osteogenesis. A complex of measures for the correction of APGS-1 and acceleration of consolidation of pathological fractures is proposed.

Mooren’s ulcer a rare cause of peripheral ulcerative keratitis

Authors report a rare cause of peripheral ulcerative keratitis. Mooren’s ulcer is a chronic, painful, relentless ulcerative peripheral keratitis that begins from periphery of cornea near limbus as narrow crescent corneal infiltrate which then progresses circumferentially and centrally. Mooren’s ulcer gets misdiagnosed as peripheral bacterial ulcer or another non-infective peripheral ulcerative keratitis.

Sclerokeratouveitis and lens dislocation in a patient with genital ulcer: was the great imitator imitated?

Uveitis is the most common ocular manifestation of syphilis, while scleritis is rare. A case of nodular scleritis, peripheral keratitis and uveitis in a patient with genital ulcer is presented...

Scleritis associated with relapsing polychondritis

AimsTo evaluate ocular disease characteristics and successful therapeutic regimens in patients with scleritis associated with relapsing polychondritis (RP). To compare these features with those seen in patients with scleritis associated...

Clinical manifestations and outcome of tuberculous sclerokeratitis

AimTo study the clinical manifestations and outcome of patients with tuberculous sclerokeratitis treated with antituberculous therapy without concomitant use of systemic steroids.MethodsWe reviewed retrospectively the medical records of eight consecutive...

Peripheral Ulcerative Keratitis with Pyoderma Gangrenosum.

Pyoderma gangrenosum is an unusual necrotizing noninfective and ulcerative skin disease whose cause is unknown. Ophthalmic involvement in pyoderma gangrenosum is an unusual event. Only a few cases have been reported, from which we can highlight scleral, corneal, and orbital cases. Peripheral ulcerative keratitis is a process which destroys the peripheral cornea. Its cause is still unknown although it is often associated with autoimmune conditions. Pyoderma gangrenosum should be included in the differential diagnosis of peripheral ulcerative keratitis. Early recognition of these manifestations can vary the prognosis by applying the appropriate treatment. We introduce a 70-year-old woman who suffered pyoderma gangrenosum associated with peripheral ulcerative keratitis in her left eye. The patient's skin lesions and peripheral keratitis responded successfully to systemic steroids and cyclosporine A.

Childhood Mucous Membrane Pemphigoid

To report a case of mucous membrane pemphigoid (MMP) occurring in childhood with exclusively ocular involvement. Case report. A 12-year-old girl presented with mild bilateral conjunctival cicatrization, symblepharon, and peripheral inflammatory keratitis. No other mucosal or cutaneous involvement was present. The findings of an initial conjunctival biopsy with immunofluorescence study were negative for MMP. After a few recurrences of mild corneal and conjunctival inflammation, a second conjunctival biopsy was performed at a different site in the same eye, 30 months later. Only then was the diagnosis of MMP confirmed using positive direct immunofluorescence. The results of a systemic investigation for autoimmune vasculitis were negative. Therapy with dapsone was introduced, and a good response was obtained. MMP is an extremely rare condition in children. This case is the second one reported with exclusively ocular involvement. Despite its rarity in the pediatric age group, MMP should be considered in the differential diagnosis of chronic conjunctival inflammation and fibrosis. Furthermore, a single negative biopsy should not exclude this diagnosis in a suspected clinical case, even in children. When a high degree of suspicion is present, a repeat biopsy may prove useful.

Feasibility of aqueous shunts for reduction of intraocular pressure in horses

Based on the current literature, neither medical, surgical nor combination therapy adequately controls equine glaucoma for many horses. Aqueous shunts have been useful in other species to control glaucoma. To determine whether aqueous shunts in normal equine eyes significantly reduce intraocular pressure (IOP) without causing vision threatening complications. Prospective experimental trial. Aqueous shunts were placed in 7 normal eyes of 4 horses. The shunts were placed dorsotemporally. Examinations were initially performed daily for 7 days and after that every 3 days through 4 weeks after implantation. Horses were then subjected to euthanasia and globes enucleated for routine histological examination. The IOPs for each day post operatively were compared to the preoperative value (Day -1) using a Wilcoxon signed ranks test. Significance was set at P<0.05. The mean IOP preoperatively (20.7 ± 3.0 mmHg) was significantly higher than on any post operative day (P values ranged from 0.018 to 0.048). The aqueous shunts remained in situ for the entire study. Two eyes developed corneal ulcers that resolved. Shallow anterior chambers were noted in 2 eyes after shunt placement, which normalised after placement of full eye cup masks. Histologically, 7/7 eyes had fibrosis surrounding the implant. Minimal peripheral neovascularisation and neutrophilic keratitis were noted in 5/7 eyes. Corneal damage was scored as none in 3/7, mild in 2/7, moderate in 1/7 and marked in 1/7 eyes. After placement of aqueous shunts, a significant decrease in IOP was noted from preoperatively (Day -1) to Day 28 despite fibrosis surrounding the implants. No vision threatening complications were noted. Aqueous shunts may represent a feasible therapeutic option for equine glaucoma. The results of this study suggest that further studies in glaucomatous horses would be warranted.

Ocular manifestations of the antineutrophil cytoplasmic antibody and antiphospholipid syndromes

Sir, I read with interest the article by Kumar Saurabh and colleagues on the patient profile of retinal vasculitis from Eastern India,[1] and would like to comment on the importance of a more comprehensive laboratory work-up to ensure that the vasculitides syndromes associated with significant morbidity and mortality are not missed. The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) and antiphospholipid antibody syndrome (APS) both can initially present with only ocular manifestations such as uveitis and work-up to exclude these vasculitides is more important in younger patients without known systemic risk factors.[2,3] The AAVs include Wegener's granulomatosis (cytoplasmic staining pattern seen on immunofluorescence of ethanol-fixed human neutrophils, cANCA, with specificity for proteinase 3 [PR3]) while microscopic polyangiitis and Churg–Strauss syndrome (usually have a perinuclear pattern on immunofluorescence, pANCA, with specificity for myeloperoxidase [MPO]) can present with various ophthalmic manifestations. But in a subset of patients, these findings may be the earliest indicators of systemic disease (up to 50% in children).[2,4] Orbital and anterior segment findings are most common, whereas posterior segment complications such as retinal vasculitis and optic neuropathy occur much less frequently. However, a study on patients with pANCA-associated vasculitis reported that ocular surface (scleritis and peripheral keratitis) and posterior segment manifestations (central or branch retinal vein occlusion, optic neuropathy, acute posterior multifocal placoid pigment epitheliopathy) were the important eye presentations.[5] However, a significant proportion of patients will have systemic symptoms, but may not initially present, and the finding of abnormal chest X ray or serum creatinine or glomerulonephritis should warrant an urgent laboratory request to exclude an ANCA-associated vasculitis. The autoimmune disease APS is characterized by the consistent presence of antiphospholipid antibodies (or anticardiolipin or anti-β2GPI antibodies) at 12 weeks, arterial or venous thromboses and repetitive foetal loss. Diluted Russel viper venom time (dRVTT) is often used as one of the phospholipid-dependent tests that shows a prolonged APTT which gets corrected only with increased phospholipid concentrations (suggesting the presence of lupus anticoagulant). This can be present without ds-DNA antibodies with a nonspecific positive antinuclear antibody (ANA) only, and hence the addition of lupus anticoagulant in the diagnostic criteria of systemic lupus erythematosus. Ocular involvement in APS occurs in 8-88% of patients, of which 75% with ocular presentation were women with mean age at 40 years.[3] Ocular findings in APS include anterior uveitis, unilateral or bilateral blurring of vision, transient scotoma, uniteral amaurosis fugax (bilateral suggests CNS ischemia), visual field defects and various retinal pathologies (hemorrhages, vasculitis, retinopathy) discussed by Utz VM and Tang J in their review.[3] Clinicians should therefore have a high index of suspicion of AAV and APS, in especially younger patients, which would be the first step in avoiding the inevitable complications of arterial inflammation and visual loss. Emphasis to lower additional risks of thrombosis such as treating cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, tobacco use or obesity), during immobilization or malignancy, treating microalbuminuria, screening for inherited thrombophilias, and counseling regarding oral contraceptive use remain equally important.

Idiopathic peripheral necrotizing keratitis after femtosecond laser in situ keratomileusis

We report a case of necrotizing peripheral keratitis after laser in situ keratomileusis (LASIK) using the low-energy Femto LDV femtosecond laser in a 31-year-old helicopter pilot with no history of medical or ocular disease. The severe peripheral flap inflammation resulted in stromal necrosis that was unresponsive to intensive topical steroid but improved rapidly on oral prednisone. The uncorrected distance visual acuity was maintained at 20/15 in both eyes, and the flaps were left undisturbed rather than attempting a more aggressive intervention such as a flap lift with culture and antibiotic irrigation. Identification of sterile corneal infiltration must be distinguished from infectious etiologies as the treatment is distinctly different. Although increased corneal infiltration has been reported with increasing femtosecond laser energy level for flap creation, to our knowledge this is the first report of necrotizing sterile corneal infiltration after LASIK with the low-energy femtosecond laser. Neither author has a financial or proprietary interest in any material or method mentioned.

Uveíte anterior na ausência de esclerite em paciente com artrite reumatóide: relato de caso

Rheumatoid arthritis is the most common collagenosis and affects almost 0.6% of Brazilian population. It is an important cause of articular deformities. The main ocular manifestation of rheumatoid arthritis is dry eyes (secondary Sjögren's syndrome), followed by scleritis, peripheral ulcerative keratitis and uveitis. The aim of this paper is to present a case of anterior uveitis in the absence of scleritis in a patient with rheumatoid arthritis, a very rare presentation in this type of patient. Female patient, 55 years old, with rheumatoid arthritis, presenting suddenly ocular pain and low vision in the right eye. Her exam showed anterior chamber reaction with hypopion, peripheral corneal keratitis and intraocular pressure of 32 mmHg. She was diagnosed with hypertensive anterior uveitis and peripheral corneal keratitis and treated with systemic and topical corticosteroids, topical antibiotic, topic and systemic ocular hypotensive and mydriatic drops. Anterior uveitis is common in rheumatological diseases, especially in those seronegative arthropathies related to HLA B27. In this paper we present a patient with rheumathoid arthritis and anterior uveitis in the absence of scleritis, a rare presentation in actual medical literature.

Management of pain with diclofenac after femtosecond-assisted laser in situ keratomileusis

To evaluate the safety and efficacy of topical diclofenac sodium 0.1% after femtosecond laser-assisted laser in situ keratomileusis (LASIK). W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA. Clinical trial. Pain was assessed in patients treated with topical diclofenac sodium 0.1% or artificial tears immediately after LASIK using a numeric pain scale and a combined picture-numeric pain scale 0, 2, 4, 12, and 24 hours postoperatively. Visual outcomes and complications were noted up to 24 hours. The study enrolled 100 eyes of 50 patients. Patients treated with diclofenac 0.1% reported less pain than the control group on both pain scales 2, 4, 12, and 24 hours after surgery, with the maximum benefit at 4 hours (P=.02). Fewer patients in the diclofenac group (76.0%) than in the control group (91.3%) used oral pain and/or anxiolytic medications during the first 24 hours after surgery (P=.25). Ninety-eight eyes had an uncorrected distance visual acuity of 20/40 or better. Mild peripheral diffuse lamellar keratitis accounted for the majority of perioperative complications (n = 15). Pain after femtosecond laser-assisted LASIK was mild and was reduced with a single dose of topical diclofenac sodium 0.1% given immediately after surgery.

Progressive Keratolysis with Pseudopterygium Associated with Erythema Elevatum Diutinum

To report a patient with a rare case of progressive keratolysis with pseudopterygium associated with erythema elevatum diutinum (EED). Interventional case report and literature review. One patient with ocular presentation of EED was identified. A 64-year-old woman presented with recurrent pterygium and painful corneal thinning with impending perforation of the left eye. Examination revealed intensely inflamed pseudopterygium, paracentral and peripheral corneal ulcerations, and descemetocele with a pinpoint leakage. Clinical course and laboratory and histopathologic findings. Disseminated skin lesions developed during hospital admission. Examination revealed multiple, well-demarcated, discrete, red to violaceous, firm nodules and plaques on the knuckles and dorsum of the hands, and the extensor surface of the forearms, elbows, knees, right ankle, and buttocks. A skin biopsy of the recent lesions showed a dense and diffuse inflammatory cell infiltration, predominantly neutrophilic infiltrates and nuclear dust (leukocytoclasis), located around small blood vessels in the dermis, consistent with the diagnosis of EED. The diagnosis of progressive keratolysis with pseudopterygium associated with EED was made. Spontaneous, rapid resolution of both cutaneous and ocular lesions occurred after dapsone therapy. Erythema elevatum diutinum is a rare, chronic, and recurrent disease that has both dermatologic and ocular manifestations. Peripheral ulcerative keratitis seems to be the most common ocular finding and may be the initial presenting feature of EED. Ophthalmologists should be aware of this rare entity in the differential diagnosis of ulcerative or nonulcerative peripheral keratitis.

Insect wing tarsal foreign body causing conjunctival granuloma and marginal keratitis

A 37 year old male was referred to our centre for management of episcleritis with peripheral keratitis in the right eye. He had a history of ocular discomfort in the right eye of 1 week duration. Slitlamp examination revealed marginal keratitis between 12'o clock to 2'o clock positions in the right eye. Lid eversion revealed an insect wing on the tarsal conjunctiva along with an adjacent conjunctival granuloma. The area of the marginal keratitis corresponded to the area of the foreign body and the conjunctival granuloma. The probable mechanism of the development of marginal keratitis and the conjunctiva granuloma is speculated in this case report.

Eye Manifestations in Patients with Perinuclear Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review

To report and summarize eye manifestations of patients with perinuclear pattern antineutrophil cytoplasmic antibody [pANCA, myeloperoxidase (MPO)-ANCA]-associated vasculitis. The medical records of four consecutive patients with pANCA (MPO-ANCA) vasculitis who showed eye manifestations were retrospectively reviewed. In addition, the medical literature databases, PubMed and Japana Centra Revuo Medicina for Japanese literature, were searched for pANCA vasculitis patients with eye manifestations. Three of the four patients treated at the Okayama University Hospital showed unilateral or bilateral scleritis. In the literature review, eight of the 27 patients showed ocular surface manifestations such as scleritis and peripheral keratitis. Other frequent eye presentations were posterior segment manifestations such as central or branch retinal vein occlusion, optic neuropathy, and acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Systemically, the most frequent manifestations were glomerulonephritis in the present patients as well as in the patients reported in the past studies. Ocular surface manifestations and posterior segment manifestations were major eye presentations in patients with pANCA-associated vasculitis. ANCA testing including both pANCA and cytoplasmic pattern antineutrophil cytoplasmic antibody would help establish a systemic diagnosis in patients with eye manifestations such as scleritis, retinal vein occlusion, optic neuropathy, or APMPPE.