Medical Care
Immune corneal ulcers are ocular surface diseases with multiple etiologies. Immunosuppressive drugs and systemic or topical steroids may control the inflammatory process in some cases, but, in more severe cases, the ulcer may progress to melting or perforations. [15, 18, 39]
The medical treatment of corneal ulcer primarily is systemic and needs to be coordinated with a corneal specialist, rheumatologist, or internist. The ophthalmologic treatment is best approached in coordination with corneal subspecialists and with other specialists of the external disease and in collaboration with an internist, as necessary. Topically applied nerve growth factor (NGF) has been used in some patients with corneal neurotrophic ulcers and corneal melting with success. [40, 41]
Medical care for corneal ulcerations includes topical and systemic corticosteroid therapy and immunosuppressive treatment.
Topical therapy
Topical agents include the following:
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Preservative free artificial tears, used with or without punctum plug and soft contact lenses. Small corneal ulcers caused by dry eye syndrome can benefit from such treatment, promoting epithelialization of the ulcer.
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Cycloplegic agents (eg, cyclopentolate TID)
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Immunosuppressive agents (eg, topical cyclosporine 0.5% in artificial tears)
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Prophylactic broad-spectrum topical antibiotics (eg, 0.3% ciprofloxacin qid) to prevent bacterial superinfection.
Systemic immunosuppressive therapy
Systemic immunosuppressive agents must be prescribed by an ophthalmologist, rheumatologist, or internist who is familiar with their dosages and adverse effects.
Start initially with intravenous methylprednisolone (eg, methylprednisolone 1 g IV administered in 1 dose over 30 minutes) or oral prednisone (1 mg/d).
Steroid-sparing agents include antimetabolites (eg, methotrexate, azathioprine, mycophenolate mofetil), T-cell inhibitors (eg, cyclosporine, tacrolimus), alkylating agents (eg, cyclophosphamide, chlorambucil) and biologic agents (eg, infliximab, rituximab). A recent study reports a case of RA-associated PUK treated successfully with rapid healing using prednisolone, methotrexate, and adalimumab combination therapy. [42]
Biologic agents are gaining popularity for the treatment of ocular manifestations of rheumatic diseases. Studies showed that rituximab can be an effective induction therapy for refractory ocular complications of RA. [5] A case series identified rituximab as having the highest success rate (63%) for achieving steroid-free remission in patients with GPA-associated PUK. The second best medication was cyclophosphamide (31% success). [43] Rituximab was also effective in the management of severe Mooren ulcer. [44]
Mooren ulcer
A 2017 study suggested treating Mooren ulcers initially with aggressive topical medication, including 1% cyclosporine or 0.1% tacrolimus eye drops, 0.1% dexamethasone, and antibacterial eye drops 4 times daily, along with tobramycin and dexamethasone ointment at night. [13] Treatment was stepped up to systemic corticosteroid therapy and immunosuppressive treatment in cases of failure. Medication was continued at full dose for at least 3 months after complete resolution of the ulcer and was slowly tapered thereafter. [13]
Surgical Care
Surgical care for corneal ulcer includes the following:
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Resection of adjacent conjunctival tissue to remove sources of collagenase, cytokines, and inflammatory cells from the ulcerated cornea
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Application of tissue adhesives such as cyanoacrylate glue to limit ulceration in cases of impending perforation: This may be effective only in small perforations. The opacity of the cyanoacrylate tissue adhesive can obscure visual axis, especially in central corneal lesions. [45]
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Tectonic (reconstructive) lamellar or penetrating keratoplasty [47] may be performed to restore normal corneal thickness in cases of thinned or perforated cornea. These are useful therapeutic options in selected cases of corneal thinning and perforations, as they effectively restore the integrity of the eye and allow acceptable visual rehabilitation. [45] However, outcomes of keratoplasty performed for a sterile ulcer are not as good those for infectious corneal ulcers, probably owing to the underlying inflammatory condition interfering with the healing process. [48]
Consultations
Patients with corneal ulcer must be treated and monitored closely by a rheumatologist because the treatment is systemic and can have serious adverse effects, and the systemic implications of these disorders can often be life-threatening. [17, 18]
Further Outpatient Care
Outpatient care for patients with corneal ulcers is essential with close follow-up.
Further Inpatient Care
Inpatient care for patients with corneal ulcers may be required in difficult cases.
