Pathology Case Presentation Corneal 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 Glue filling perforated cornea Infiltrate Edge of contact lens 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 Lymphocytes Neutrophil

Corneal ulcer/thinning Full thickness cornea Disorganized epithelium Endothelium lost in processing Thinning Stromal scarring 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. FINAL DIAGNOSIS: CORNEA, LEFT EYE, CORNEAL TRANSPLANT A. MILD ACUTE AND CHRONIC KERATITIS WITH EXTENSIVE SCARRING AND PIGMENT ENTRAPMENT IN ULCER BED (see comment) B. THINNED REGENERATIVE EPITHELIUM C. FOCAL REGION OF RETROCORNEAL FIBROSIS