Earlier Treatment Better Controls Peripheral Ulcerative Keratitis

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Late immunosuppressive therapy is a risk factor for visual loss in patients with rheumatoid arthritis-associated peripheral ulcerative keratitis, according to a study.

Patients with rheumatoid arthritis (RA)-associated peripheral ulcerative keratitis (PUK) who receive early immunosuppressive therapy (IMT) are more likely to experience less recurrences, earlier control of inflammation and better visual outcomes, according to a study published in the British Journal of Ophthalmology

Researchers sought to examine the role of early IMT in the management of RA-associated PUK. They divided patients with RA-associated PUK into 2 groups according to receiving early (<4 weeks) or late (>4 weeks) IMT after PUK onset. Study outcomes included PUK recurrence, control of inflammation and development of ocular complications, such as permanent vision loss, corneal scarring, corneal perforation and cataract formation or progression.

The researchers analyzed 52 eyes from 36 patients of Mexican-mestizo descent (mean age 55.9±11.4 years, 29 women, 7 men) with a clinical diagnosis of PUK associated with RA. A total of 24 (46.2%) eyes also had concomitant diffuse anterior scleritis, 11 (21.2%) eyes had nodular scleritis, and 8 (15.4%) eyes had necrotizing scleritis. Of the 52 eyes, 37 (71.2%) eyes received early IMT and 15 (28.8%) received late IMT. The average follow-up time was 41.2+53.3 months (range: 4–236 months). 

The team identified early IMT as a protective factor for PUK relapse (HR 0.345, 95%CI 0.126 to 0.946, P =.039). While achieving inflammatory control >2 months (HR 8.37, 95% CI 1.88 to 37.16, P =.005) and a recent diagnosis of RA (HR 4.93, 95% CI 1.75 to 13.85, P =.002) were risk factors for PUK recurrence. 

Risk factors for visual loss were late IMT (OR 7.75, 95% CI 2.00 to 29.99, P =.003), an unknown diagnosis of RA at first visit (OR 4.14, 95% CI 1.15 to 14.91, P =.030) and at least one PUK recurrence (OR 6.42, 95% CI 1.71 to 24.07, P =.006). The survival analysis showed that eyes exposed to early IMT had a lower risk of recurrence (P =.039). 

“Patients with PUK must undergo a hasty diagnostic workup to discard infection and initiate prompt and aggressive IMT. Close collaboration between ophthalmologists and rheumatologists is required to adequately establish, titrate and manage drug-induced complications of IMT,” according to the researchers. “The present study shows that vision loss, cataract progression, corneal scarring, disease recurrence and corneal perforation are severe complications associated with PUK.”

Study limitations include its retrospective nature, limited sample size of patients, and patients with a known RA diagnosis are more likely to undergo IMT or receive early treatment following PUK onset. 


Ruiz-Lozano RE, Ramos-Davila EM, Garza-Garza LA, Gutierrez-Juarez K, Hernandez-Camarena JC, Rodriguez-Garcia A. Rheumatoid arthritis-associated peripheral ulcerative keratitis outcomes after early immunosuppressive therapy. Br J Ophthalmol. Published online April 13, 2022. doi:10.1136/bjophthalmol-2022-321132