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Peripheral Ulcerative Keratitis

(Marginal Keratolysis; Peripheral Rheumatoid Ulceration)

By Melvin I. Roat, MD, FACS, Clinical Associate Professor of Ophthalmology; Cornea Service, Sidney Kimmel Medical College at Thomas Jefferson University; Wills Eye Hospital

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Peripheral ulcerative keratitis is inflammation and ulceration of the cornea that often occurs with chronic connective tissue diseases. Irritation and decreased vision result.

Peripheral ulcerative keratitis is a serious corneal ulceration; it often occurs with autoimmune connective tissue diseases that are active, long-standing, or both, such as RA, granulomatosis with polyangiitis (formerly called Wegener granulomatosis), and relapsing polychondritis.

Patients often have decreased visual acuity, photophobia, and foreign body sensation. A crescentic area of opacification in the periphery of the cornea, due to infiltration by WBCs and ulceration, stains with fluorescein. Infectious causes, such as bacteria, fungi, and herpes simplex virus, must be ruled out by culturing the ulcer and eyelid margins.

Among patients with autoimmune connective tissue disease and peripheral ulcerative keratitis, the 10-yr mortality rate is about 40% (usually due to MI) without treatment and about 8% with systemic cytotoxic therapy.

Any patient with peripheral ulcerative keratitis should be promptly referred to an ophthalmologist. Systemic cyclophosphamide or other immunosuppressants treat the keratitis, life-threatening vasculitis, and underlying autoimmune disease. Treatment also includes local approaches to control inflammation (eg, tissue adhesive and bandage contact lenses) and repair damage (eg, patch grafts). Other possibly helpful drugs include collagenase inhibitors, such as systemic tetracycline or topical 20% N-acetylcysteine.

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