A 76-year-old man was referred to our service for progressive redness and pain in the right eye. Six months earlier, his disease had been diagnosed as conjunctivitis, episcleritis, and senile furrow degeneration and he had been unsuccessfully treated with topical tobramycin/dexamethasone. His ocular and medical history and review of systems were unremarkable. BCVA in the right eye was 20/25 and slit-lamp examination revealed limbal injection, fine inferior keratic precipitates, and temporal corneal thinning with an overlying epithelial defect that measured 5 mm vertically and 2 mm horizontally and stained with fluorescein. The presumptive diagnosis of PUK was made and the patient was started on moxifloxacin q.i.d., doxycycline 100 mg bid, vitamin C 1 g bid, and topical lubricants.
Lab workup was notable for positive purified protein derivative (PPD) and QuantiFERON gold. Cyclic citrullinated peptide antibody test, a marker for rheumatoid arthritis, was also positive. All other laboratory assays were unremarkable and chest x-ray was normal. An infectious disease specialist was consulted at this time who recommended isoniazid, pyridoxine, and rifampin for the treatment of latent tuberculosis. We also consulted the rheumatology service that recommended we proceed with immunosuppression using prednisone 1 mg/kg and mycophenolic acid.
His condition improved after one month and a prednisone taper was initiated. However, PUK recurred, at which point oral prednisone was restarted at the original moderate dose and amniotic membrane was placed via a PROKERA lens (Bio-Tissue, Doral, FL) to promote epithelial corneal healing. He returned two weeks later with worsening keratitis at which point the lens was removed and topical prednisolone acetate t.i.d. was initiated. Symptoms stably improved for three months, after which he was very slowly tapered off topical and systemic prednisone. At his last visit, 16 months after presentation, he remains asymptomatic with a BCVA of 20/30.  Figure 2 demonstrates a slit-lamp photograph taken at presentation and AS-OCT images taken before and after treatment. The etiology for this patient's PUK was deemed related to his autoimmune disorder with possible rheumatoid arthritis. Given the need for immunosuppression, antituberculosis medications were initiated under the care of an infectious disease specialist.