Online Photo Diagnosis

By Gregory W. DeNaeyer, OD, FAAO

This photograph shows the left eye of a patient who presented with peripheral ulcerative keratitis (PUK). This 75-year-old white female complained of redness, photophobia, and mild pain in both of her eyes that had initiated two weeks prior to her examination with a corneal specialist. Systemically she was being treated for hypertension and asthma. Her entering visual acuity with glasses was 20/70 in her right eye and count fingers in her left eye. Slit lamp examination of both eyes showed superior corneal thinning, epithelial loss, neovascularization, and infiltration. The left eye, which also had central edema and mild anterior chamber flare, was considerably worse than the right eye. She was diagnosed with bilateral PUK and prescribed preservative-free artificial tears every two hours and erythromycin ung. q.i.d. Collagen plugs were inserted into both of her lower puncta. The patient was immediately referred to a rheumatologist to rule out systemic disease.

PUK is a destruction of the perilimbal cornea that is mediated by collagenolytic and proteolytic enzyme release from inflammatory cells^1,2. Differential diagnoses include microbial keratitis, phlyctenulosis, vernal keratoconjunctivitis, and Mooren's ulcer³. PUK is often associated with collagen vascular disease including rheumatoid arthritis, Wegener's granulomatosis, polyarteritis nodosa, and systemic lupus erythematosus^4,5. Ophthalmic management involves keeping the eye lubricated and preventing infection and perforation.

A rheumatologist eventually diagnosed this patient with sicca syndrome. Restasis (Allergan), warm compresses, and oral doxycycline were eventually added to her ophthalmic treatment regimen. To date, after one month of therapy, she has experienced significant improvement and her visual acuity is 20/40 OD and 20/100 OS.

References

1. Shyamsundar, K. Biswas, J. Narayanan, K. Immunosuppresives in Perpheral Ulcerative Keratitis. MJAFI. 2005;61:195-196.
2. Sainz de la Maza M. Foster, CS. The diagnosis and treatment of peripheral ulcerative keratitis. Seminars in Ophthalmology. 1991;Vol 6(no.3):133-41.
3. Moreira, AT. Prafna, NV. Acanthamoeba as a cause of peripheral ulcerative keratitis. Cornea. 2003;22(6):576-7.
4. Robbin, JB. Shanzlin, DJ. Verity, SM. et al. Peripheral corneal disorders. Surv Ophthalmol. 1986;31:1-36.
5. Aldave, AJ. Shih, JL. Jovkar, S. et al. Peripheral keratitis associated with erythema elevatum diutinum. Am J Ophthalmol. 2003;135:389-90.