A Description of the Pathological Features of Rheumatoid Corneal Melt Strategies

A 34 year old woman with a 20 year history of rheumatoid arthritis (RA) presented with a 1 day history of blurred vision in her right eye. Three years earlier she had developed a corneal melt, which had stabilised with a combination of lubricants, topical cyclosporine and a short course of oral prednisolone, and was regularly monitored. Her arthritis had been quiescent for several years on etanercept. Examination of the right cornea revealed a 3 mm descemetocele – an area of corneal stromal melting characterised by total loss of corneal stroma down to Descemet’s membrane, the basement membrane of the corneal endothelium – that was leaking aqueous humour and causing shallowing of the anterior chamber. This is represented in the anterior segment photo (Figure 1) as the dark circular area within the area of corneal scarring. The corneal epithelium was fully intact and the eye was white and quiet. After an attempt at gluing of the perforation, she underwent a tectonic corneal transplant and was prescribed tacrolimus to reduce the risk of allograft rejection. After 3 uneventful years, the corneal transplant was clear, her unaided visual acuity was 20/30 and the tacrolimus was discontinued. On histological examination, the descemetocele was characterised by a fully intact corneal epithelium and Descemet’s membrane with complete loss of corneal stroma (Figure 2). The adjacent stroma was thinned and disorganised and showed a mild inflammatory infiltrate.