Transcript Pathology Case Presentation

Pathology Case Presentation
Corneal Melt
Jeremy B. Wingard, MD
Case History
• 55 year old female with longstanding
history of panuveitis OS.
• Past medical history includes Lupus and
Sjogren’s syndrome.
• She is maintained on systemic
methotrexate and prednisone, as well as
ocular prednisolone and intermittent
periorbital steroids during flares.
Acute Presentation
• Patient developed increasing pain and
decreased vision in the two days following
a subtenon’s 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.
After second gluing
Glue filling
perforated
cornea
Infiltrate
Edge of
contact
lens
Hypopyon
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
TNFα).
• At this point a scar developed, and the eye
was quiet. Corneal transplant was
undertaken.
Post-transplant
Host
tissue
Clear
corneal
graft
Mixed acute and chronic
inflammation
Neutrophil
Lymphocytes
Corneal ulcer/thinning
Full thickness cornea
Disorganized
epithelium
Endothelium
lost in
processing
Thinning
Stromal
scarring
Stromal
pigment
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.
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
Diagnosis
CHRONIC PANUVEITIS COMPLICATED BY
INFECTIOUS AND IMMUNE-MEDIATED
KERATITIS AND CORNEAL MELT.