Corneal Melt- don’t always blame Rheumatoid Arthritis (RA)
Dr Asif Munir Dr Claire Sheehy
Department of Rheumatology, Waterfrod University Hospital
Corneal melt is a rare inflammatory disease of the peripheral cornea; it may lead to perforation of the globe and visual failure. Corneal melt can be a manifestation of systemic vasculitis in patients with RA and other conditions, such as cancer. Without early and aggressive treatment it may be associated with a poor visual outcome and high mortality. It has been reported in patients with stable RA.
A 75 year old male with a background of sero positive Rheumatoid Arthritis presented to the Eye Casualty with a two week history of a painful left red eye. His other medical history was significant for Stage IIB poorly differentiated cancer of the left lower lobe since 2017. He was awaiting biopsy of renal mass ?metastatic lung disease vs primary renal carcinoma. His RA was well controlled on Methotrexate 10mg weekly. He described sharp eye pain, waking him from the sleep, associated with watery discharge and photophobia. He had been treated by the ophthalmology team for left marginal Keratitis for the past 2 months with steroid eye drops. Examination showed corneal melt in left eye involving 25% of inferior portion of the cornea and spastic entropion with injecting eye lashes. CRP was 4.1. He had a negative ANA and ANCA; viral swabs were negative. He had no active joints and there were no other signs of vasculitis He was admitted under the medical team. Intravenous Methyl Prednisolone was started. The patient felt better after 5 days of Methyl Prednisolone. Cyclophosphamide was initiated after discussion with Oncologist pending the result of the renal biopsy.
The renal biopsy was positive for metastatic Squamous Cell Carcinoma of lung. The cornea improved with complete resolution of his visual symptoms.
In this case, although the history of RA was felt by the ophthalmology team to be the most likely association with the corneal melt, we would argue the oncological diagnoses were likely the driving force behind the presentation.