Factors involved in managing corneal perforations associated with rheumatoid arthritis

(Image Credit: AdobeStock/Yura Yarema)

Wolfgang Bernauer, MD, lead author from the Eye Clinic, University Hospital, Zurich, Switzerland, and colleagues from Moorfields Eye Hospital and Institute of Ophthalmology, London, reported that the type of surgical procedure, predominant pathogenic mechanism, and the perioperative immune status affect the outcomes of patients with rheumatoid arthritis with ocular involvement.¹

The investigators explained that sterile corneal ulceration is a rare complication of rheumatoid arthritis and may lead to corneal perforation. However, surgeries performed to restore vision often are not successful.

In light of this, the authors analyzed the factors that may determine why corneal surgery fails in patients with corneal perforations associated with rheumatoid arthritis.

The investigators analyzed the cases of 29 patients (32 eyes) with rheumatoid arthritis with corneal perforations that required surgery. Twenty corneal lesions were classified as necrotizing keratitis and 12 as ulcers secondary to surface disease. The classification was based on the most evident primary pathology.

The research team evaluated the outcomes of different methods of primary repair, specifically, application of tissue adhesive, lamellar graft, or penetrating keratoplasty, and graft survival in penetrating keratoplasties.

A total of 57 corneal procedures were done in the 32 eyes. The authors reported that primary repair was successful in five eyes (25%) with necrotizing keratitis and in eight eyes (67%) with perforations secondary to the surface disease. They defined success as no need for additional corneal surgery within 6 months.

They also found that use of tissue adhesive as a long-term treatment, was unsuccessful in all five eyes.

Immunosuppression significantly improved the survival of first penetrating grafts (42% graft survival after 1 year versus 11 % without immunosuppression, p = 0.02), Dr. Bernauer reported. Of 25 graft failures, 20 (80%) developed as the result of recurrent melts up to 6 months after penetrating keratoplasty. Ocular surface infection was responsible for failure in 6 of 10 grafts after that time.

Based on their findings the authors concluded, “The complications of corneal surgery in rheumatoid corneal perforations are frequent. The type of surgical procedure, the predominant pathogenic mechanism, and the perioperative immune status influence the outcome. The control of corneal melting and the prevention of surface infection are critical for graft survival.”

Reference:

1. Bernauer W, Ficker LA, Watson PG, Dart JKG. The management of corneal perforations associated with rheumatoid arthritis. An analysis of 32 eyes. Ophthalmology. doi:https://doi.org/10.1016/S0161-6420(95)30867-6