Outcome of penetrating keratoplasty in rheumatoid arthritis

Keratolysis in rheumatoid arthritis is a well-known disorder that may rapidly destroy the entire corneal stroma, resulting in descemetocele formation and eventually corneal perforation. The purpose of this study was to determine the anatomical and functional results of therapeutic penetrating keratoplasty (PK) in these patients.

We reviewed the charts of patients having undergone PK over a 5-year period and evaluated the outcome. In 16 eyes of 15 patients, PKs were performed (graft diameter 3.0-11.0 mm) because of corneal melting with perforation or descemetocele formation. In 9 eyes, we used topical cyclosporine A (2%) as an adjunct therapy after transplantation in addition to systemic immunosuppressive agents.

Following a mean follow-up time of 17 months, anatomical success could be achieved in all eyes; none of the eyes underwent enucleation or evisceration. Postoperative complications following the first PK were epithelial keratopathy in 8 eyes (50%), corneal ulceration in 5 eyes (31%), fistulation in 4 eyes (25%), suture loosing in 4 eyes (25%) and graft rejection in 2 eyes (13%). Additionally 5 regrafts were required because of recurrence of corneal melting or persistent deep stromal defects. Comparison of complications of the patients receiving topical cyclosporine A to the control group showed a statistically significant lower incidence of epithelial keratopathy (p < 0.025) and ulcer recurrence in the cyclosporine A group during the first 3 months postoperatively (p < 0.05). The final best corrected visual acuity was 20/40 in 4 eyes but was limited to 20/200 or less in 7 eyes.

Whereas PK can be successful to restore the anatomical integrity of severely altered eyes, the high prevalence of complications limits the indication for PK as a last stage procedure when other methods of management have failed. The use of topical cyclosporine A as adjunct therapy needs further evaluation.