Bilateral scleromalacia in rheumatoid arthritis

Abstract

A 35-year-old lady presenting with deforming seropositive rheumatoid arthritis (RA) (Fig. 1a) of 8-year duration involving multiple small and large joints was initially on over-the-counter analgesics like Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Five months back, she had high disease activity with a DAS28-CRP of 5.52 when she was put on methotrexate 15 mg per week and leflunomide 10 mg per day. Two months later she started complaining of acute onset pain, redness, and blurring of vision in both eyes. Her articular symptoms persisted with a DAS28-CRP of 5.2. Prior to the onset of the ocular symptoms, she had a good vision with no subjective complaints. Slit-lamp examination showed a violaceous hue of the bilateral bulbar sclera and dilated scleral vessels with areas of microvascular occlusion. Dilated retinal examination revealed cystoid macular edema (CME). She was diagnosed as having anterior necrotizing scleritis with CME and received high-dose systemic steroids with a rapid taper over 2 weeks along with topical steroid drops. There was no improvement in her vision though her joint pains and global symptoms improved partially. The dose of methotrexate and leflunomide was increased to 20 mg per week and 15 mg per day respectively in view of high disease activity. Two months back, she was admitted with visual acuity of 6/18 in the right eye and 6/36 in the left eye. Her DAS28-CRP was 4.92 at the time of admission. After ruling out tuberculosis, syphilis, and herpes infection, she received 5 mg/kg infliximab at 0, 2, and 6 weeks, which improved her vision to 6/9 and 6/12 in her right and left eye respectively. Methotrexate was continued, and leflunomide * Rashmi Roongta