Rheumatology Advance Access originally published online on May 25, 2006
Rheumatology 2006 45(7):921-922; doi:10.1093/rheumatology/kel143
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LETTER TO THE EDITOR |
Re: Use of intravenous cyclophosphamide in the prevention of peripheral ulcerative keratitis
1 Department of Rheumatology, St Helens and Knowsley NHS Trust, St Helens Hospital, Merseyside, 2 Rheumatic Disease Unit, Royal Liverpool University Hospital, Liverpool and 3 Department of Opthalmology, St Pauls Eye Unit, Royal Liverpool Univesity Hospital, Liverpool, UK
Correspondence to: Dr A. R. Clewes, Department of Rheumatology, St Helens and Knowsley NHS Trust, St Helens Hospital, Merseyside, UK. E-mail: Adrian.Clewes{at}sthkhealth.nch.uk
SIR, Liu and Chan are confused in their assumptions. In our report, we described two patients with rheumatoid arthritis, who had previous peripheral ulcerative keratitis (PUK) leading to the perforation of the eye [1]. We discuss the repeated use of cyclophosphamide to prevent recurrence of the vasculitis manifesting as a PUK. The development of PUK following previous surgery is well-recognized [2]. Sainz de la Maza et al. [2] found that patients with peripheral keratopathy were 4.8 times more likely to have had previous ocular surgery. In particular, they noted that PUK was significantly associated with previous ocular surgery in 58.3%, and was the most frequent peripheral keratopathy found after cataract surgery [2]. Vaso-occlusive changes are prominent in the episclera adjacent to the site of the PUK [3], and histologically there is an inflammatory micro-angiopathy of the episcleral and conjunctival vasculature [4].
In contrast, surgically induced necrotizing sclerokeratitis may be associated and precipitated by a variety of conditions such as a localized infection or inflammation around a suture, and may not be associated with a systemic connective tissue disorder. The two patients we have reported had an underlying connective tissue disorder with an evidence of a previous vasculitis. As has been reported, the inflammatory micro-angiopathy in PUK may be caused by the extension of the systemic process or a local immune response triggered by trauma such as surgery, with immune complex-mediated vasculitic damage [5]. The prevention of the further development of PUK or associated scleritis by the use of cyclophosphamide in the peri-operative period underlines this point.
The authors have declared no conflicts of interest.
References
- Clewes AR, Tunn EJ, Kaye S, Bucknall RC. Use of intravenous cyclophosphamide in the prevention of corneal melt: justified or not?. Rheumatology 2005;44:257–8.
[Free Full Text] - Sainz de la Maza M, Foster S, Jabbur NS, Baltatzis S. Ocular characteristics and disease associations in scleritis-associated peripheral keratopathy. Arch Ophthalmol 2002;120:15–9.
[Abstract/Free Full Text] - Watson PG. Vascular changes in peripheral corneal destructive disease. Eye 1990;4:65–73.[Medline]
- Tauber J, Sainz de la Maza M, Hoang-Xuan T, Foster CS. An analysis of therapeutic decision-making regarding immunosuppressive chemotherapy for peripheral ulcerative keratitis. Cornea 1990;9:66–73.[Medline]
- Sainz de la Maza M, Foster CS. Necrotizing scleritis after ocular surgery. Ophthalmology 1991;98:1720–6.[Medline]
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