Pathology Case PresentationCorneal Melt

Jeremy B. Wingard, MD

Case History

• 55 year old female with longstanding history of panuveitis OS.

• Past medical history includes Lupus and Sjogren’s syndrome.

• She is maintained on systemic methotrexate and prednisone, as well as ocular prednisolone and intermittent periorbital steroids during flares.

Acute Presentation

• Patient developed increasing pain and decreased vision in the two days following a subtenon’s Kenalog injection.

• Exam in ER: Corneal ulcer OS (three distinct infiltrates) with inferior corneal thinning.

• Treated as inpatient for infectious keratitis (cultures positive for group A Streptococcus). Eventually cornea perforated and was glued twice.

After second gluing

Edge of contact lens

Glue filling perforated cornea

Infiltrate

Hypopyon

Further course

• Immune melt of the cornea continued, with persistent hypopyon, infiltrates, and thinning.

• Course reversed after patient received several doses of Remicade (Infliximab, monoclonal antibody against human TNFα).

• At this point a scar developed, and the eye was quiet. Corneal transplant was undertaken.

Post-transplant

Host tissue

Clear corneal graft

Mixed acute and chronic inflammation

LymphocytesNeutrophil

Corneal ulcer/thinningFull thickness cornea

Thinning

Disorganized epithelium

Stromal scarring

Endothelium lost in processing

Stromal pigment

Discussion

• Autoimmune inflammatory disease presents a great difficulty clinically when the course involves infection.

• Although it is imperative to control inflammation, all anti-inflammatory therapies are inherently pro-infectious and so must be delayed.

• In this case, the patient had a proven bacterial infection, but her response to infection, with corneal melt, was far beyond the normal response.

• Clinical practice is to treat infection aggressively initially, then start anti-inflammatory therapy.

Corneal Stromal Pigment Differential

• Iris pigment – post-perforation with iris prolapse, likely in this case.

• Corneal tattoo – rule out by history

• Corneal blood staining – possible to induce hyphema with surgery, although not noted clinically in this case

• Metallic foreign body – sometimes found despite negative history

Diagnosis

CHRONIC PANUVEITIS COMPLICATED BY INFECTIOUS AND IMMUNE-MEDIATED KERATITIS AND CORNEAL MELT.