Severe extra-articular manifestations of rheumatoid arthritis usually occur in advanced stages of the disease. In particular, ocular involvement may lead to inflammatory corneal ulceration, in which therapy is challenging owing to its association with systemic vasculitis. Close collaboration between ophthalmologists and rheumatologists is paramount in providing the best treatment approach in this sight-threatening condition.
We present a case of seropositive rheumatoid arthritis associated with corneal melting in the absence of other typical clinical manifestations of rheumatoid arthritis flare. The rheumatoid arthritis-associated corneal ulcer was complicated in our case by concomitant infection with methicillin-resistant Staphylococcus aureus, which was treated with intravenous vancomycin after an initial antimicrobial ophthalmic solution proved not to be making adequate improvement in the corneal healing. The recurrent corneal melting appeared to be aggravated by the ophthalmic infection while on immunosuppressive regimen.
In patients on biologic agents, intravenous antibiotics must be considered in addition to ophthalmic eye solution in controlling the infectious process. Excluding concomitant ophthalmic infection is equally important before initiation of high-dose steroid and immunosuppressive regimens.