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Sir,

A common complication of rheumatoid arthritis (RA) is dry eye, which can compromise the ocular surface and predispose it to infective keratitis. Both RA and infective keratitis can lead to corneal melt but this rarely results in the extrusion of intraocular contents. We report a case of spontaneous lens extrusion in a patient with dry eyes and infective keratitis.

Case report

A frail 96-year-old lady with previously well-controlled RA and dry eye presented to her GP with a 3-day history of a red and gritty dry eye. There had been no perception of light in this eye for several years due to rubeotic glaucoma secondary to central retinal vein occlusion. Conjunctivitis was diagnosed and topical fucithalmic produced an encouraging initial response. After 6 days, she presented to eye casualty holding her spontaneously extruded crystalline lens (Figure 1). Examination revealed a corneal abscess with a considerable area of corneal melt resulting in a large open wound exuding pus (Figure 2).

Figure 1
figure 1

Spontaneously extruded crystalline lens.

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Figure 2
figure 2

Total central corneal melt through which the crystalline lens was extruded. Exuding pus with prolapsed uveal tissue also present.

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Corneal cultures identified a heavy growth of Pseudomonas aeruginosa that had probably been contracted from a hospitalisation for gastrointestinal bleeding 2 weeks prior. Management with topical and systemic antibiotics to prevent spread of infection was instigated. The eye settled and became phthisical.

Comment

In the context of RA, corneal melting and perforation are more likely in the presence of microbial keratitis and dry eyes.1 Although P. aeruginosa cannot penetrate intact epithelium, once it does infect the cornea it can release a host of proteolytic enzymes and toxins causing additional direct lytic damage to the collagenous structure of the cornea. Untreated this can lead to rapid ulceration, stromal necrosis, and perforation.2

Lens expulsion is an uncommon complication of corneal melting. It has been previously reported in association with Kwashiorkor,3 in premature infants,4 in an obtunded patient with nosocomial keratitis,5 and after anterior chamber intraocular lens implantation in the presence of concurrent illness such as RA, herpes zoster ophthalmicus, and glaucoma.6,7

In an increasingly ageing population, it is of utmost importance that early signs of corneal involvement in RA patients are recognised and treated promptly. This is especially true of the debilitated or recently hospitalised elderly. This is the only reported case we found that shows corneal melting allowing extrusion of the crystalline lens in a patient with RA during infective keratitis.