29 EyeWorld Asia Pacific | June 2024 Dr. Ahmad said there may be some challenges with confirming a diagnosis because many other conditions can mimic PUK. He expanded on the differential diagnosis to also include infectious keratitis, herpes viral keratitis, and staph marginal keratitis. “Differentiating between these entities can be challenging and requires a careful history and physical exam,” he said. To treat PUK, Dr. Ahmad said patients typically require systemic steroids to control 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. Topical prophylaxis with antibiotics is important to prevent bacterial superinfection,” he said. “Additionally, oral Doxycycline and vitamin C can help prevent corneal thinning by inhibiting matrix metalloproteinase activity and promoting collagen synthesis, respectively. Ultimately, many patients will need to bridge to steroid-sparing therapy for long-term control of PUK.” Dr. Ahmad added that co-management with rheumatology 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 condition is not well controlled. With each recurrence, 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 About the Physicians Ashraf Ahmad, MD | Cataract, Cornea & Refractive Surgery, Harvard Eye Associates, Laguna Hills, California | aahmad@harvardeye.com Sanjay Kedhar, MD | Clinical Professor of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California | skedhar@hs.uci.edu Relevant Disclosures Ahmad: None Kedhar: None This article originally appeared in the March 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. of the eye with preservative-free artificial tears and punctal occlusion to promote epithelial healing as well as oral doxycycline and vitamin C. Cyanoacrylate glue can be useful in cases of more severe thinning to limit ulceration. The conjunctiva 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 Methotrexate, Mycophenolate mofetil, Azathioprine tacrolimus, Cyclophosphamide, Chlorambucil, Adalimumab, Infliximab, or Rituximab.” Dr. Kedhar said that treatment should be geared toward arresting ongoing tissue destruction 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 progression should stop. If the corneal thinning is excessive or there is perforation, surgical intervention including corneal patch grafts, crescentic 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: Sanjay Kedhar, MD CORNEA
RkJQdWJsaXNoZXIy Njk2NTg0