Necrotising Scleritis and Peripheral Ulcerative Keratitis Associated with Rheumatoid Arthritis Treated with Rituximab

Abstract

Rheumatoid arthritis is a chronic and common inflammatory autoimmune disease. This primarily involves the synovia of the joints, but can cause many extra-articular manifestations as well, including peripheral ulcerative keratitis (PUK) and necrotising scleritis. These are often a threat to vision; they significantly compromise not only the eye's structural integrity but are also important for prognosis and need urgent management. Three cases of peripheral ulcerative keratitis associated with rheumatoid arthritis were recorded in the electronic databank of the Jules Gonin Uveitis Clinic, two with necrotising scleritis and peripheral ulcerative keratitis and one with only peripheral ulcerative keratitis. They were all followed at Jules Gonin Eye Hospital (Lausanne, Switzerland), conjointly with the Department of Rheumatology at the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland). Good initial therapeutic response was observed in the two patients who received rituximab therapy. The patient who received only high dose corticosteroid developed massive colon perforation as well as acute renal insufficiency a few days after her ocular event. From our limited number of patients, we found that the two patients who received the induction therapy with rituximab were stabilised from an ocular standpoint; however, rituximab had to be switched to other molecules, either due to other systemic symptoms from the disease itself or due to adverse effect of this treatment. This contributes to the increasing number of reports that rituximab can be an effective treatment for refractory ocular complications of rheumatoid arthritis (RA), at least as an induction therapy.

Two cases of perforated corneal ulcers complicating rheumatoid arthritis treated successfully by biological therapy

“…Etanercept has been reported to treat sterile corneal ulceration in inflammatory disease, but it is used with some uncertainty according to some articles [29,31]. Some cases of PUK related to RA alone or associated with scleritis, have been improved successfully with Rituximab as a treatment [1,32]. Our cases suggest the efficacy of these biologic agents as a treatment of this severe and destructive keratolysis of the cornea complicating an active RA and exposing the patient to the risk of blindness.…”

“…Among these ocular manifestations, peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea in which corneal meltdown develops in juxta-limbal location. Untreated, it can progress from marginal corneal thinning to perforation, which represents the most severe ocular complication leading to vision loss [1,8]. The prevalence of PUK is 1 to 3% according to some studies [3,6].…”

“…Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease involving primarily the synovium of joints but can affect other organs including the eye. The ocular manifestations that can occur during the course of RA or that can be the initial sign of the disease are multiple and can include dry-eye syndrome, episcleritis, scleritis, sclero-uveitis, retinal vasculitis and peripheral ulcerative keratitis [1,2]. Physicians can misdiagnose that ocular involvement.…”

“…Therefore, early diagnosis and treatment are recommended in collaboration with the ophthalmologists [3]. Recently, PUK in patients with RA has become less common due to improved treatment of RA particularly with biological therapies [1]. Few publications reported the effectiveness of the biologic agents as a treatment of PUK related to RA.…”

Anti-IL-6 Receptor Tocilizumab in Refractory Graves’ Orbitopathy: National Multicenter Observational Study of 48 Patients

“…TCZ has shown promising results in the treatment of different inflammatory ocular diseases, especially in uveitis [ 33 , 34 , 35 , 36 ]. However, reports on TCZ in inflammatory orbitopathies are scarce [ 37 , 38 , 39 , 40 , 41 ]. Within the spectrum of inflammatory orbitopathies, GO is a severe complication of GD producing high morbidity, leading to loss of vision in some patients.…”