Pathology Case Presentation

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Pathology Case Presentation

• Corneal Melt

Jeremy B. Wingard, MD
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Case History

• 55 year old female with longstanding history of
  panuveitis OS.
• Past medical history includes Lupus and Sjogrens
  syndrome.
• She is maintained on systemic methotrexate and
  prednisone, as well as ocular prednisolone and
  intermittent periorbital steroids during flares.

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Acute Presentation

• Patient developed increasing pain and decreased
  vision in the two days following a subtenons
  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.

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After second gluing
Glue filling perforated cornea
Infiltrate
Edge of contact lens
Hypopyon
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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 TNFa).
• At this point a scar developed, and the eye was
  quiet. Corneal transplant was undertaken.

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Post-transplant
Host tissue
Clear corneal graft
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Mixed acute and chronic inflammation
Lymphocytes
Neutrophil
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Corneal ulcer/thinning
Full thickness cornea
Disorganized epithelium
Endothelium lost in processing
Thinning
Stromal scarring
Stromal pigment
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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.

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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

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Diagnosis

• CHRONIC PANUVEITIS COMPLICATED BY INFECTIOUS AND
  IMMUNE-MEDIATED KERATITIS AND CORNEAL MELT.