A Myriad of Co-conspirators Leading to Ulcerative Keratitis

Introduction. Ulcerative keratitis is attributed to an array of infectious, non-infectious, and immune etiologies. Case presentation. A 47 year old Hispanic female presents with decreased vision, photophobia and pain OS > OD that had worsened since starting new eye drops (FML 0.1% BID OU and Voltaren 0.1% BID OU) two weeks prior. Ocular history is significant for keratoconjunctivitis sicca and Epithelial Basement Membrane Dystrophy. Systemic history is remarkable for Sjogren’s syndrome, MALT Lymphoma, anemia and presumed discoid Lupus. Visual acuity is 20/50 OD with NI on pinhole and 20/200 OS with 20/100 on pinhole. Corneal biomicroscopy shows 4+ diffuse PEK with (+) NaFl and (+) RB staining OU, instant TBUT OU, and a 3.5mm round epithelial/sub-epithelial defect with surrounding edema superior-nasal OS. Management included discontinuation of FML and Voltaren, Tobrex ung TID OU and pressure patching OS with full re-epithelialization of the ulcer in 3 days. Deviation From the Expected. The etiology of this ulcerative keratitis case is multifactorial including autoimmune disease, severe dry eye, a history of corneal basement membrane abnormality, use of topical NSAIDs, and an immunomodulating agent (Rituxan) associated with dry eye. Discussion. Immune related ulcers are generally peripheral, whereby sterile or infectious corneal ulcers can be either peripheral or central. Pathogenesis of autoimmune corneal ulcers is unknown. It has been proposed that the immune system is responding to unknown antigens resulting in antibody production and activation of complement pathway. Conclusion. The patient’s autoimmune disease, corneal disease, and overall systemic health contributed to the severe nature of the presentation