Here we describe the clinical case of a female patient, who was 43 years old at initial visit at our department. She presented with bilateral tearing and ocular pain persisting for 7 months. The patient had no operations or any ocular diseases in the past medical history. The patient had no internal diseases and did not take any drugs in the last months.
At the initial examination, the corrected visual acuity was 6/6 in both eyes. In the right eye, slit-lamp examination showed mild conjunctival hyperemia and an inferior crescent-shaped corneal ulcer with limbal involvement but no associated scleritis (Fig. 1). In the left eye, slit-lamp examination showed mild conjunctival hyperemia and a superior crescent-shaped corneal ulcer with limbal involvement but no associated scleritis (Fig. 2). In both eyes, there was perilesional haziness and the fluorescein stain was positive (indicating overlying epithelial defect). Also, in both eyes, there was no sign of corneal infection (purulent secretions or infiltrates), corneal sensitivity was preserved. A tear film study demonstrated decreased Schirmer test results (5 mm in both eyes) and tear film break-up time (5 sec in both eyes). There was no inflammatory reaction in the anterior chamber and no signs of retinal vasculitis.
Systemic evaluation for underlying diseases causing peripheral ulcerative keratitis included: Complete Blood Count (CBC), complete Metabolic Profile (CMP), urinalysis with microscopic analysis, infectious serology, angiotensin converting enzyme (ACE), X-ray chest and joints, accessory salivary gland biopsies and autoimmune screenings (for rheumatoid factor, antinuclear antibody, anti-neutrophil cytoplasmic antibody and anti-DNA antibody).
The patient was treated topically with 1% prednisolone acetate six times a day, 0,3% sodium hyaluronate frequently and oral systemic prednisolone at 1 mg/kg/day for 15 days.
The patient observed an increased pain and redness in both eyes. The slit-lamp examination revealed a deep corneal ulcer. Amniotic membrane transplantation with conjunctival resection was done in the area of melt were done in both eyes (to fill the corneal defect and to promote the corneal cicatrization) (Fig. 3, 4).
Nevertheless, the amniotic membrane was rapidly reduced without corneal reconstruction or healing and there was circumferential thinning which was progressing in both eyes (figure (5).
The patients ocular symptoms kept on worsening which led to the supposition that we missed the diagnosis. So, we went back to the interrogation and the patient revealed he had recurrent skin lesions in both legs with chronic itching, and recurrent oral and genital ulcers healing spontaneously.
We supposed a possible diagnosis could be Behcet’s disease. A further assessment was requested to confirm the diagnosis of Behçet; Pathergy test was negative (Fig. 6), HLA B51 was positif. And following international diagnostic criteria for Behçet’s Disease, we kept the diagnosis of Behçet. Systemic therapy was started with colchicine at a dose of 2 mg/day. Eye drops and systemic prednisolone at 1 mg/kg/day was continued with progressive decrease.
After 2 weeks, the ocular pain was relieved and the conjunctival hyperemia improved. At 1 month of treatment, symptoms were absent. The corrected visual acuity was 10/10 in both eyes. Slit-lamp examination showed healed corneal lesion with stromal thinning and mild haziness (Fig. 7).
The follow up at 3 months and 6 months showed no signs of recurrence of ulceration in both eyes.