Recurring corneal melts in patients with rheumatoid disease may respond
best to aggressive therapy which can include biologic modalities such as
infliximab, an inhibitor of tumour necrosis factor-alpha (TNFα),
according to a case study presented by Dipak Parmar FRCOphth, FRANZCO,
London, UK, at the Cornea Day session at the 16th EsCRs Winter Meeting.
The patient was a 47-year-old sri Lankan man who initially presented in
October 2006 with a corneal perforation in his right eye with 80 per
cent corneal thinning and 20 per cent corneal thinning in his left eye,
Dr Parmar noted. his visual acuity was 6/19 in his right eye and 6/9.5
in his left eye. Both eyes had a peripheral inferonosal gutter at 3 to 6
o'clock.
The patient's medical history included rheumatoid
arthritis of five years' duration which was systemically quiescent and
managed under a rheumatologist at another hospital. his current regimen
included prednisolone 4mg per day and methotrexate 7.5mg per week,
together with calcium carbonate, alendronic acid and diclofenac. Dr
Parmar initially treated him with corneal glue repair and increased the
prednisolone dosage to 60mg per day (plus ranitidine) and gradually
increased his methotrexate dosage to 20mg per week over the next three
months.
In February 2007 the patient had a repeat corneal
perforation in his right eye. Dr Parmar again treated the eye with
corneal glue repair together with multilayered amniotic membrane
transplantation and Parasol punctual plugs (Odyssey) in both eyes. The
patient also received a low dosage of methotrexate, 2.5mg per week, and
his condition remained stable for a year at which point he was lost to
follow-up.
Two years later he returned to the clinic with
corneal perforations in both eyes (Figure 1). Dr Parmar performed
bilateral simultaneous tectonic penetrating keratoplasties and increased
his methotrexate dosage to 10mg per week and prednisolone to 60mg per
day. however, just one month after the penetrating keratoplasties there
was a repeat corneal perforation in the patient's right eye. he
underwent corneal glue repair on three further occasions and had his
methotrexate dosage increased to 25mg per week. he also received topical
cyclosporine 0.05 per cent (Restasis) twice a day in both eyes.
In
July 2009 the patient underwent repeat penetrating keratoplasty with
amniotic membrane graft overlay in his right eye. however, the graft was
not successful and he required yet another penetrating keratoplasty
within a week. In addition, the graft in the patient's other eye
developed paracentral thinning, which continued unabated despite the
application of a multilayered amniotic membrane graft, high-dose
methotrexate and corneal glue repair.
Unfortunately the patient
had developed adverse reactions to azathioprine and cyclophosphamide,
which meant that there were very few treatment options left. At this
point infliximab was suggested as a treatment option to Dr Parmar by his
rheumatologist colleague. Infliximab is an anti-TNFα chimaeric
monoclonal antibody that prevents TNFα binding to cellular receptors and
induces apoptosis in TNFα- expressing activated T-cells.
Immediately
after undergoing a repeat tectonic graft in his left eye, the patient
commenced intravenous therapy with infliximab administered every six
weeks. At 30 months post infliximab both corneas were stabilised, with
no evidence of disease progression (Figure 2). His best corrected visual
acuity was 6/48 in the right eye and 6/36 in the left, limited by
pre-existing corneal subepithelial haze. Dr Parmar concluded: "I would
definitely encourage those of you managing patients with corneal melts
secondary to rheumatoid or other inflammatory conditions to consider
these biological agents."
