Atypical continuous keratitis in a case of rheumatoid arthritis accompanying severe scleritis

Rheumatoid arthritis (RA) often presents with ocular complications: typically dry eye, peripheral corneal ulcer, and scleritis. We report for the first time a case of severe scleritis with RA, accompanying atypical continuous keratitis, which apparently differs from typical peripheral ulcerative keratitis (PUK).

Observational case report.

A 68-year-old woman with RA presented at our hospital complaining of worsening arthritis accompanying ocular injection and discharge. On examination, nodular scleritis and peripheral corneal infiltration were noted. In addition to administering topical steroid and antibiotics, cyclosporine and an oral steroid were added because of the patient's worsening scleritis. Despite gradual improvement of the scleritis, the efficacy of the additional treatments was limited. Four months after initial treatment, the patient presented with uveitis, thought to be caused by a herpetic virus. Antivirus treatment was effective for the uveitis, but atypical continuous keratitis suddenly appeared. The keratitis was located from 4-o'clock to 10-o'clock positions continuously in the midperipheral cornea and apparently differed from herpetic keratitis or PUK as typically seen in RA cases. Immune reaction was suspected, and the keratitis improved within 2 weeks. After that, the introduction of an anti-tumor necrosis factor α drug (infliximab) completely resolved the severe scleritis and there was no recurrence of ocular inflammation.

As is shown in this case, RA can present with atypical continuous keratitis, thought to be a manifestation of an immunologic reaction other than PUK. In addition, although immunosuppressants are often used for the treatment of RA with scleritis, the efficacy is limited. Infliximab may be a useful treatment for treatment-resistant scleritis.