Conjunctival resection in the management of peripheral ulcerative keratitis

Purpose: To present a case with refractory peripheral ulcerative keratitis (PUK) that was managed with conjunctival resection surgery in addition to medical treatment.
Material and Method: A 78-year-old female patient was admitted with sudden decrease in vision, redness and pain in the right eye. Her medical history was unremarkable except for early stage diabetes and hypertension. In the first examination, her visual acuities were counting fingers from 1 meter in the right eye and 1.0 in Snellen lines in the left eye. Biomicroscopy revealed crescent-shaped stromal ulceration with accompanying epithelial defect, stromal thinning and limbal inflammation in the temporal cornea consistent with PUK.Immediate management included bandage contact lens application, topical preservative-free dexamethasone, moxifloxacin, cyclosporine 0.05%, polyvinyl alcohol/povidone artificial tear eye drops, as well as I.V. pulse metiprednisolone. Rheumatology consultation revealed no underlying autoimmune disease. During her follow-up with oral maintenance dose streoids and topical medication, the ulcer progressed to perforation with protrusion of the iris. Therefore, surgical correction including conjunctival resection and amniotic membrane transplantation (AMT) had to be performed.
Results: In follow-up, healing in stromal ulceration was observed with dramatic improvementin ocular surface inflammation. Visual acuity improved to 0.2 in the 3rd month. Her cornea was transparent, anterior chamber was quiet, and PUK area was healed with no epithelial defect. The patient was followed up under topical cyclosporine and carboxy-methylcellulose maintenance therapy.
Conclusion: In PUK cases refractory to I.V. pulse steroid or immunosuppressive therapy, "conjunctival resection" surgery may be a useful tool in the armamentarium of cornea specialists, in order to remove perilimbal immune complexes, suppress inflammation and accelerate surface healing