The
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Bilateral Corneal Perforation
Nathaniel Nataneli, M.D. Ophthalmic Consultants of Long Island Rockville Centre, NY
Jean S.M. Chai, M.D. Singapore National Eye Center Singapore, Singapore
A
B
C
D
A
61-year-old woman with long-standing rheumatoid arthritis presented with the sensation that she had a foreign body in her right eye; she reported no symptoms in her left eye. The patient had systemic symptoms associated with her rheumatoid arthritis, with no synovitis, and was receiving treatment with naproxen. Evaluation revealed corneal perforations in both eyes, with iris prolapse, resulting in irregular pupils. She also had cataracts, probably long-standing, since she was unperturbed by her visual acuity — 20/400 in the right eye and 20/200 in the left eye (Panels A and B, respectively). Notably, the conjunctivas were uninjected. The erythrocyte sedimentation rate was 110 mm per hour. Oral steroids were started before the initiation of methotrexate, and corneal-patch grafting was performed. The anatomical integrity of both eyes was preserved, albeit with persistent defects in the iris (Panel C, right eye after surgical repair; Panel D, left eye after surgical repair), but acuity was limited to 20/150 in the right eye and 20/100 in the left eye owing to progressive cataracts. Cataract surgery was deferred until these issues were resolved. Corneal perforations are a surgical emergency. Progression may be prevented by the administration of immunosuppressive treatment directed at the underlying rheumatoid arthritis.
DOI: 10.1056/NEJMicm1303823 Copyright © 2014 Massachusetts Medical Society.
650
n engl j med 370;7
nejm.org
february 13, 2014
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF EXETER on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Bilateral Corneal Perforation
Nathaniel Nataneli, M.D. Ophthalmic Consultants of Long Island Rockville Centre, NY
Jean S.M. Chai, M.D. Singapore National Eye Center Singapore, Singapore
A
B
C
D
A
61-year-old woman with long-standing rheumatoid arthritis presented with the sensation that she had a foreign body in her right eye; she reported no symptoms in her left eye. The patient had systemic symptoms associated with her rheumatoid arthritis, with no synovitis, and was receiving treatment with naproxen. Evaluation revealed corneal perforations in both eyes, with iris prolapse, resulting in irregular pupils. She also had cataracts, probably long-standing, since she was unperturbed by her visual acuity — 20/400 in the right eye and 20/200 in the left eye (Panels A and B, respectively). Notably, the conjunctivas were uninjected. The erythrocyte sedimentation rate was 110 mm per hour. Oral steroids were started before the initiation of methotrexate, and corneal-patch grafting was performed. The anatomical integrity of both eyes was preserved, albeit with persistent defects in the iris (Panel C, right eye after surgical repair; Panel D, left eye after surgical repair), but acuity was limited to 20/150 in the right eye and 20/100 in the left eye owing to progressive cataracts. Cataract surgery was deferred until these issues were resolved. Corneal perforations are a surgical emergency. Progression may be prevented by the administration of immunosuppressive treatment directed at the underlying rheumatoid arthritis.
DOI: 10.1056/NEJMicm1303823 Copyright © 2014 Massachusetts Medical Society.
650
n engl j med 370;7
nejm.org
february 13, 2014
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF EXETER on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
