Wiezorrek R, Bialasiewicz A A, Engelmann K, Grasedyck K, Richard G
Augenklinik, Universitäts-Krankenhaus Eppendorf, Hamburg.
Ophthalmologe. 1998 Sep;95(9):619-24. doi: 10.1007/s003470050324.
Areactive forms of keratitis in patients with seropositive rheumatoid arthritis are inflammations threatening the visual acuity and integrity of the eye. They commonly occur in a rheumatologically inactive interval and have a poor prognosis. A retrospective evaluation of medicamentous and surgical strategies for a curative therapy with optical rehabilitation is necessary to optimise the treatment of patients with necrotic sclerokeratitis.
A total of 27 eyes of 22 patients (14 women and 8 men, ranging in age at the time of operation from 40 to 88 years; mean 68.7 years) with seropositive rheumatoid arthritis and secondary Sjögren's syndrome were reviewed retrospectively. There were 17 eyes with necrotic keratitis and 9 eyes with necrotic sclerokeratitis. In one eye, necrotic sclerokeratitis with bacterial transmigrating keratitis and hypopyon occurred.
In 8 cases we performed a perforating mini-keratoplasty, in 16 cases a tectonic and optical perforating keratoplasty, in 3 cases a tectonic sclerokeratoplasty, in 9 patients a combined keratoplasty and cataract extraction with posterior chamber lens implantation and in 1 case a partial conjunctival plasty. Follow-up ranged from 7 months to 4 years (average 2.8 years).
In all eyes, a sufficient tectonic and primary curative effect was achieved only under cyclophosphamide immunosuppression. In 3 cases, a rekeratoplasty had to be performed because of recurrent keratitis after changing the systemic cyclophosphamide therapy to methotrexate, glucocorticosteroids or non-steroid antiphlogistic agents. Visual acuity outcome was depending on the eccentricity of the keratoplasty and earlier affections of the eye. Postoperatively, the visual acuity improved in 23 eyes. In 3 cases, no change of visual acuity was achieved. Visual acuity deteriorated in one case from counting fingers to hand motions. Peri- and postoperative complications during the follow-up period were corneal infiltration around sutures in 4 eyes, graft rejecting reactions in 3 cases, and sicca syndrome in 6 cases.
The intensive cooperation of ophthalmologists and rheumatologists enables the successful treatment of apparently hopeless situations in necrotic sclerokeratitis in patients with seropositive rheumatoid arthritis. The rate of complications under an immunosuppressive therapy with cyclophosphamide was found at average 2.8 years follow-up to be low. The indication for the combined therapy depends on the ophthalmological findings; rheumatologists and ophthalmologists should decide on the appropriate dosage for the systemic cyclophosphamide therapy. Topical glucocorticosteroid therapy alone is contra-indicated.
血清反应阳性类风湿关节炎患者的反应性角膜炎是一种威胁视力和眼完整性的炎症。它们通常发生在风湿病非活动期，预后较差。有必要对药物和手术策略进行回顾性评估，以采用光学康复的根治性治疗方法，从而优化坏死性巩膜角膜炎患者的治疗。
回顾性分析22例血清反应阳性类风湿关节炎继发干燥综合征患者的27只眼（14例女性，8例男性，手术时年龄40至88岁；平均68.7岁）。其中17只眼为坏死性角膜炎，9只眼为坏死性巩膜角膜炎。1只眼发生坏死性巩膜角膜炎合并细菌感染性角膜溃疡及前房积脓。
8例行穿透性微型角膜移植术，16例行结构性及光学性穿透性角膜移植术，3例行结构性巩膜角膜移植术，9例联合角膜移植及白内障摘除并植入后房型人工晶状体，1例行部分结膜成形术。随访时间为7个月至4年（平均2.8年）。
所有患眼仅在环磷酰胺免疫抑制下获得了足够的结构性及初步根治效果。3例在将全身环磷酰胺治疗改为甲氨蝶呤、糖皮质激素或非甾体抗炎药后因复发性角膜炎而需再次行角膜移植术。视力结果取决于角膜移植的偏心度及眼部早期病变情况。术后23只眼视力提高。3例视力无变化。1例视力从指数下降至手动。随访期间的围手术期及术后并发症包括4只眼缝线周围角膜浸润、3例移植排斥反应及6例干燥综合征。
眼科医生和风湿病医生的密切合作能够成功治疗血清反应阳性类风湿关节炎患者坏死性巩膜角膜炎这种看似无望的情况。在平均2.8年的随访中发现，环磷酰胺免疫抑制治疗下的并发症发生率较低。联合治疗的适应证取决于眼科检查结果；风湿病医生和眼科医生应决定全身环磷酰胺治疗的合适剂量。单独局部应用糖皮质激素治疗是禁忌的。
