Case History. Patient demographics: - 74 year old Caucasian White Female

Transcription

1 Peripheral Ulcerative Keratouveitis in a patient with Rheumatoid Arthritis Primary Author: Rebecca Lande, OD White River Junction VHA Resident Optometrist Secondary Author: Richard Frick, OD, FAAO Abstract This case report examines a rheumatoid arthritis patient with peripheral ulcerative keratouveitis and will discuss the ocular manifestations and treatment options for patients with rheumatoid arthritis. Case History Patient demographics: - 74 year old Caucasian White Female VISIT #1: Chief complaint: - Patient presented to the Emergency Room and the optometry resident was paged on the weekend. The patient complained of foreign body sensation OD 1 day prior to visit. Patient attempted flushing eye with water last night with no improvement. (+) watering, (+) light sensitivity, pain level 3/10 one day ago, and 2/10 presently Ocular/medical history: - New to eye clinic. Pseudophakia with PCIOL OU. Medical history is positive for Rheumatoid Arthritis (RA), GERD, Abnormal Liver Function, Herpes Simplex, Carpal Tunnel Syndrome. Patient s RA is managed at Dartmouth-Hitchcock Medical Center (DHMC) Medications: - ASA 325mg po qd, Celecoxib 200mg po bid, Cetirizine HCL 10MG po qd, Cyanocobalamin 100 MCG tab qd, Folic acid 1mg po qd, Hydroxychloroquine sulfate 200mg po qd, Methotrexate 2.5mg po q1wk Pantoprazole 40mg po bid, Vitamin D 1000IU po qd, 500mg Infliximab in sodium chloride 0.9% 300 ml infusion q8wks. Pertinent Findings Clinical: VISIT #1: VA: OD 20/30-1 PH NI OS 20/40-2 PH NI Pupils: Equal, round, reactive to light OU EOM's: no pain or diplopia Lids/Lashes: grade 1 crusts/flakes upper lashes OU Sclera/Conjunctiva: grade 2+ deep red injection, more concentrated superior bulbar conjunctiva OD, trace diffuse injection OS Cornea: 11:00 Peripheral, shallow corneal defect with surrounding inflammation/infiltrate in an arch shape, 1mm long x 0.5mm wide, lesions stains with Fl, (-) dendrites Anterior Chamber: 1- cells with no flare OD, Clear and quiet OS Cyclopleged using 1gtt 0.25% Scopolamine OD

2 PLAN: Patient was prescribed Scopolamine 0.25% bid OD, Gentamicin ointment tid OD, Refresh artificial tears 3-4x per day RTC: 2 days VISIT #2: Symptoms: vision feels blurry from ointment, right eye is sensitive to light, but eye feels better today, 0/10 pain level OD VA: OD 20/50 PH NI OS 20/40-2 PH NI Pupils: Equal, round, reactive to light OU Lids/Lashes: clear and quiet OU Sclera/Conjunctiva: grade 2 deep red injection, more concentrated superior/temporal bulbar conjunctiva OD, trace diffuse injection OS Cornea: 11:00 shallow ulcer with surrounding inflammation in an arch shape, 1.2mm long x 0.5mm wide, lesions stains with Fl, (-) dendrites Anterior Chamber: 2+ cells with trace flare OD, Clear and quiet OS Post-phenylephrine blanch OU: Bulbar conjunctiva OD: grade 1 injection superiorly, appears mostly episcleral, but some deeper injection present Bulbar conjunctiva OS: clear -Conjunctiva Culture obtained and sent to lab Internal with 78 Diopter lens, 20 Diopter with BIO: Lens: OD PC-IOL, trace PCO, centered OS PC-IOL, trace PCO, centered Vitreous: Syneresis OD Nerve: healthy, distinct rims OD OD C/D: 0.30/0.30 Macula: even pigment, no macular edema OD Vessels: normal course and caliber OD PLAN: Continued with Scopolamine 0.25% bid OD, Gentamicin ointment tid OD, Refresh artificial tears 3-4x per day RTC: 2 days VISIT #3: Symptoms: vision feels blurry from ointment, eye is still sensitive to light, 0/10 pain level OD VA: OD 20/40 PH NI OS 20/40 PH NI Pupils: Equal, round, reactive to light OU Lids/Lashes: clear and quiet OU Sclera/Conjunctiva: grade 1 deep red/blue injection, more concentrated superior and perilimbal bulbar conjunctiva OD, trace diffuse injection OS Cornea: 11:00 corneal defect0.5mm x 0.5mm, minimal Fl staining, 1.0mm long x 0.5mm wide inflammation surrounding, grade 2 diffuse SPK

3 Anterior Chamber: grade 1 cells with no flare OD, Clear and quiet OS Culture of conjunctiva OD: grew 3+ Staphylococcus epidermidis, 1+ Staphylococcus aureus PLAN: Continued with Scopolamine 0.25% bid OD, d/c Gentamicin ointment, start Refresh artificial tears 4-6x per day, start Vigamox qid OD. Consulted Dartmouth Rheumatology started oral prednisone pulse to reduce inflammation: 60mgx2days, 40mgx2days, 20mgx2days, 10mgx2 days, then d/c. Educate patient to use her prescribed ranitidine and protinix. Nurse practitioner in rheumatology will consider increasing methotrxate and/or remicade injections. RTC: 5 days VISIT #5: Symptoms: vision feels blurry from eye drops. Pain level is 0/10. Patient has some GI upset since starting oral prednisone, but symptoms improved when started taking stomach medications. Current stomach meds: protonix, ranitidine, and tums. VA: OD 20/40 PH NI OS 20/40 PH NI Pupils: Equal, round, dilated OU Patient put scopolamine OU instead of OD only. Lids/Lashes: trace crusts OU Sclera/Conjunctiva: trace bulbar conjunctiva injection OU Cornea: 1+ SPK on temporal cornea OD, small area of SPK at 11:00 OD, trace edema at 11:00 OD Anterior Chamber: rare cell OD, deep and quiet OS PLAN: Patient educated to continue with Scopolamine 0.25% 1 gtt qd OD x 3days then d/c, Vigamox 1gtt qid OD x 3 days then d/c, Refresh tears 1 gtt OU 4-6x per day, and to finish course of oral steroids as directed. Patient also educated to continue with tums, ranitidine, and protonix for GI upset. RTC in 1 week for anterior segment check or STAT if red eye or pain Physical: N/A Laboratory studies: Culture of conjunctiva OD: grew 3+ Staphylococcus epidermidis, 1+ Staphylococcus aureus Radiology studies: N/A Differential diagnosis Primary: Peripheral Ulcerative Keratouveitis OD

4 Others: -Staph Marginal Keratitis - Herpes Simplex -Bacterial Keratitis Diagnosis and discussion Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune disease that affects primarily synovial joints, but can also affect other tissues including the eye, pleura, and pericardium. The disease has unknown pathogenesis, and females are three times more often affected than males. 1 RA usually presents in the fourth decade with presentation of at least four of the following seven criteria: greater than 6 weeks of morning stiffness, polyarthritis, arthritis involving hand joints, symmetrical arthritis, rheumatoid nodules, positive serum rheumatoid factor, or characteristic radiographic changes of joints. 1,2 RA can present with a variety of ocular manifestations. RA patients with associated ophthalmic disease tend to be patients with severe, long-standing RA with high titers of rheumatoid factor. 1 Ocular manifestation RA: -Keratoconjunctivitis sicca secondary to Sjogren syndrome -Scleritis -Peripheral Ulcerative Keratitis -Superior Oblique tendon sheath syndrome (rare) This case presented with peripheral ulcerative keratitis (PUK) with concurrent uveitis and episcleritis. PUK is thinning of the juxtalimbal corneal stroma with associated epithelial defect and stromal edema. The cause of PUK can be either sterile or infectious (including herpes simplex, fungus, hepatitis, syphilis). A sterile PUK is usually associated with systemic collagen vascular disease, most commonly RA. 3 Pathogenesis for PUK is still not clear, but many believe that immune complex deposition attracts inflammatory cells that release the cytokine, Tumor Necrosis Factor-α (TNF-α). TNF-α causes the production of matrix metalloproteinases (MMP s) which can dissolve the corneal epithelial basement membrane and stroma if not regulated appropriately by inhibitors of MMP s. 3 Keratitis in RA most often is associated with adjacent scleritis, but it can also be an isolated finding. 1 Due to presence of deeper injection of the bulbar conjunctiva, this case was at high suspicion for scleritis. Scleritis can occur in up to 20% of RA patients, and episcleritis can occur in up to 11%. 1 Since this case had a quick resolution, low amount of pain, and blanching with instillation of Phenyleprine, the patient likely only had a moderate episcleritis. Presence of scleritis or episcleritis in a RA patient is often an indicator of worsening systemic disease and warrants re-evaluation of the patient s current medical therapy. 1 Therefore, we consulted the patient s nurse practitioner at a private hospital who was managing her RA. This patient also presented with a long history of dry eye symptoms and had currently been using artificial tears as needed for dry eye symptoms. Keratoconjunctivitis sicca is seen in up to 25% of RA patients, and symptomatic patients are usually patients with long-standing RA. Patients will present with symptoms of grittiness, burning, irritation, and clinically can have a decreased tear meniscus, decreased tear production, and/or punctuate epithelial keratopathy. Dry eye symptoms can be escalated when blepharitis or meibomitis is present along with keratoconjunctivitis sicca. 1

5 This case had one finding that did not fit the RA associated keratitis which was the growth of Staphylococcus epidermidis and Staphylococcus aureus on the bulbar conjunctival culture obtained after 3 day course of gentamicin treatment. The most common organisms identified in bacterial keratitis are Pseudomonas, Staphylococci, and Streptococci. 1 Corneal culturing was not performed due to our low suspicion of bacterial cause, but could have provided more insight in whether bacteria was the culprit of the corneal ulceration. Marginal Keratitis due to Staphylococcus is commonly associated to a secondary blepharitis. Marginal Keratitis usually presents with a small corneal ulcer less than 1 clock hour long and has a zone of clear zone approximately 1 mm wide between the ulcer and the limbus. Patients with marginal keratitis also have an intensity of symptoms that is much greater than expected based on the objective findings. In contrast, this case presented with very mild symptoms in the presence of a moderate sized corneal ulcer. 1 Treatment and Management RA associated PUK, bacterial ulcer, and possibly herpes simplex keratitis were all possible diagnoses in this cause, so the patient was started on topical antibiotics initially for possible bacterial origin (gentamicin ointment tid) and cycloplegic agent for the secondary uveitis. Due to high suspicion of the RA association, the patient s nurse practitioner was contacted and a decision of a quick pulse of oral steroids was started to calm any acute inflammatory processes due to systemic disease. Oral corticosteroids are a common treatment for keratitis and scleritis associated with RA. Conversely, topical steroids should be used with great caution because they may lead to increased thinning and possible corneal perforation. The suggested dosage to calm acute inflammation in scleritis and PUK is 1 mg/kg/day with a slow taper.1 In this case, the cornea and inflammation had already started to recede on its own, so we chose to do a quick pulse of oral steroids tapered over 8 days. (60mg for 2 days, 40mg for 2 days, 20mg for 2 days, 10 mg for 2 days, then discontinue). Immunosuppressive therapies have also been shown to be effective for treatment of RA related keratitis and scleritis. 1,2,3 The most common disease modifying antirheumatic drug (DMARD) is methotrexate which is an antagonist of tetrahydrofolic acid. Oral methotrexate in doses of 10-25mg/week has been shown effective in cases of scleritis that are unresponsive to oral corticosteroid treatement. 1 Methotrexate is co-administered with folic acid (1-2mg) to prevent side effects such as nausea, diarrhea, cytopenias, and elevation of hepatic transaminases. 1 In this case our patient was taking methotrexate 2.5mg once per week. Studies have shown treatment with Infliximab infusions has been effective at rapidly arresting progression of PUK and necrotizing scleritis in RA patients. 4,5,6 Infliximab is a neutralizing antibody to TNF-α and it disrupts the cascade of events that produces MMPs which in theory will decrease the dissolution of corneal epithelial basement membrane and stroma that occurs in PUK. 3 Infliximab injections are usually started at 3mg/kg dose then repeated at week 2, 6, and then given every 8 weeks. 6 In this case our patient was already receiving Infliximab injections every 8 weeks at an unknown dosage. After consulting with patient s nurse practitioner in rheumatology, increasing or adjusting frequency of dosage of methotrexate and/or Infliximab would be considered at next rheumatology visit due to recent ocular manifestations. Treatment for dry eye associated with RA initially includes use of artificial tears and /or ointments, but if these are unsuccessful more aggressive therapies include: short course of mild topical steroid, topical 20% autologous serum, and cyclosporin A (Restasis). When blepharitis and meibomitis are present treatment can also include lid hygiene, oral tetracyclines, and fish oil. 1 Conclusion When a patient with rheumatoid arthritis presents with a corneal ulceration, it is important to remember the mainstay of treatment is to control systemic inflammation with proper medical therapy through co-

6 management with patient s rheumatologist. Topical antibiotic treatment may be initiated to prevent or treat secondary bacterial infection, and topical cycloplegic should be used when indicated to control pain, decrease iritis, and prevent posterior synechiae. Careful ocular examination is crucial to identify and treat other potential ocular associations such as episcleritis, scleritis, keratoconjunctivitis sicca, and uveitis.

7 Bibliography 1. Krachmer, Jay H., Mark J. Mannis, and Edward J Holland. Cornea 2 nd Edition Volume 1. Elsevier Inc Kanski, Jack J. Clinical Ophthalmology 6 th. Ed. Oxford, Butterworth-Heinemann-Elsevier Ltd Odorcic, S., E. C. Keystone, et al. (2009). "Infliximab for the Treatment of Refractory Progressive Sterile Peripheral Ulcerative Keratitis Associated With Late Corneal Perforation: 3-Year Follow-Up." Cornea 28(1): Priyanka Doctor, M., Pooja Bhat, MD, and C. Stephen Foster, MD, FACS, FACR (2008). "Peripheral Ulcerative Keratitis." Contemporary Ophthalmology 7(23): Atchia, I. I., C. E. Kidd, et al. (2006). "Rheumatoid Arthritis-Associated Necrotizing Scleritis and Peripheral Ulcerative Keratitis Treated Successfully With Infliximab." JCR: Journal of Clinical Rheumatology 12(6): Odorcic, S., E. C. Keystone, et al. (2009). "Infliximab for the Treatment of Refractory Progressive Sterile Peripheral Ulcerative Keratitis Associated With Late Corneal Perforation: 3-Year Follow-Up." Cornea 28(1): 89-92