Eyeworld

SPRING 2024 | EYEWORLD | 85 C Contact Ahmad: aahmad@harvardeye.com Kedhar: skedhar@hs.uci.edu Relevant disclosures Ahmad: None Kedhar: None the local inflammation. "Topical steroids can be employed but often do not totally control the condition. They should be used judiciously, as they can promote further corneal thinning. Top- ical prophylaxis with antibiotics is important to prevent bacterial superinfection," he said. "Addi- tionally, oral doxycycline and vitamin C can help prevent corneal thinning by inhibiting matrix metalloproteinase activity and promoting col- lagen synthesis, respectively. Ultimately, many patients will need to bridge to steroid-sparing therapy for long-term control of PUK." Dr. Ah- mad added that comanagement with rheumatol- ogy is necessary for many of these patients. According to Dr. Ahmad, PUK flare-ups can resolve with treatment, however, recurrence is common, particularly if the underlying con- dition is not well controlled. With each recur- rence, there is risk of corneal melt, perforation, scaring, and irregular astigmatism, which can lead to permanent loss of vision. Dr. Ahmad added that approximately one- third of patients have an associated scleritis on presentation. It is important to evaluate for this and consider a B-scan if posterior scleritis is suspected. Dr. Kedhar said that treatment of PUK will be based on the nature of the underlying disease. For autoimmune disorders, treatment consists of local and systemic treatment. Local therapy includes aggressive lubrication of the eye with preservative-free artificial tears and punctal occlusion to promote epithelial healing as well as oral doxycycline and vitamin C. Cya- noacrylate glue can be useful in cases of more severe thinning to limit ulceration. The conjunc- tiva in the area of inflammation can be recessed, and cyanoacrylate or amniotic membrane can be placed in the defect to limit inflammation and tissue destruction. "Oral steroids are preferred over topical steroids due to increased risk of keratolysis with topical administration," Dr. Kedhar said. "Oral steroids should be used aggressively at high doses initially to reduce tissue loss. In severe cases, patients with rheumatoid arthritis or disease that is not completely responsive to steroids or poorly controlled diabetics, systemic immunosuppression should be considered. A variety of agents can be used including meth- otrexate, mycophenolate mofetil, azathioprine tacrolimus, cyclophosphamide, chlorambucil, adalimumab, infliximab, or rituximab." Dr. Kedhar said that treatment should be geared toward arresting ongoing tissue destruc- tion and inflammation. Even with adequate treatment, the areas of corneal thinning will remain. Depending on the amount of residual tissue left, surgical procedures can be tailored toward reinforcing any areas of weakness, he said. It can recur, especially if any underlying disease is not treated adequately. The epithelial defect should heal completely with appropriate treatment. "Corneal stromal thinning generally does not reverse with medical treatment, but pro- gression should stop. If the corneal thinning is excessive or there is perforation, surgical inter- vention including corneal patch grafts, crescen- tic keratoplasty, or corneoscleral procedures can be considered," he said. Dr. Kedhar said that ophthalmologists should be vigilant to rule out systemic disease or infection. A 79-year-old with a history of psoriasis, not on any immunomodulatory therapy, presented with a crescent-shaped ulcer at the limbus. After treatment with oral steroids, the patient had complete resolution of the corneal infiltrate and epithelial defect. Source: Ashraf Ahmad, MD

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