Copyright 1998 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Wilson and colleagues1 - 3 reported an association between Mooren ulcer and chronic infection with hepatitis C virus (HCV) in 4 patients. Interferon alfa-2b, an effective therapy for some patients with HCV, caused at least a temporary remission of eye disease in their 4 subjects.3 We report another case of keratitis responsive to treatment with interferon alfa-2b in which a focused medical evaluation revealed HCV infection.
A 54-year-old white man was referred for a corneal degeneration. His medical history included abnormal findings on liver function tests, diabetes mellitus, vitiligo, and Graves disease that had been treated with radioactive iodine. The patient described bilateral redness and discomfort over the previous 5 years that was responsive to treatment with topical corticosteroids. Best-corrected acuity was 20/20 OD and 20/60 OS. Both eyes had diffuse conjunctival hyperemia. The right cornea demonstrated mild thinning in the superior and inferior peripheries. The left eye had vasodilated and thickened nasal conjunctiva. There was 300° of peripheral, corneal thinning. Neovascularization extended onto the nasal cornea. The epithelium was intact. A posterior subcapsular cataract was present on the left cornea. There was no evidence of blepharitis or meibomian gland dysfunction.
A medical evaluation disclosed no clinical evidence of rheumatologic disease. Heptatis C virus antibodies were detected as was HCV RNA by polymerase chain reaction techniques (HCV Amplicor Assay, Roche, Inc, Branchburg, NJ). Laboratory tests included elevated values for alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, and direct bilirubin. Total complement and C3 complement levels were reduced. An ultrasound showed a coarsened liver texture and hepatosplenomegaly that were suggestive of cirrhosis and portal hypertension. Data from other laboratory tests included normal or negative values for erythrocyte sedimentation rate, complete blood cell count, rheumatoid factor, antinuclear antibody, antineutrophil cytoplasmic antibodies, VDRL, purified protein derivative (tuberculin), total bilirubin, alkaline phosphatase, and hepatitis B surface antigen.
We prescribed 3 million units of interferon alfa-2b subcutaneously 3 times a week. Several days after initiating therapy, conjunctival vasodilation diminished, and he discontinued the topical corticosteroid regimen. The interferon alfa-2b was given empirically for 8 months, but 5 months after discontinuation of this treatment, bilateral vasodilation, peripheral corneal infiltrates, and progressive stromal thinning recurred (Figure 1).
Five months after discontinuing treatment with interferon alfa-2b. Left, In the right eye, there is thinning of the superior and inferior, peripheral cornea. Peripheral infiltrates are present from the 6-o'clock to 8-o'clock positions. Right, The left eye has circumferential, peripheral thinning as demonstrated by poor visualization of the peripheral iris detail. A peripheral infiltrate is present inferotemporally.
This case demonstrates a milder form of keratitis than previously described in association with HCV, but it shares the features of bilaterality, chronicity, inflammation, a lack of evident systemic autoimmune disease, and a transient response to treatment with interferon alfa-2b. Possible mechanisms for keratitis include antigenic mimicry, in which host immunity against hepatitis C antigens cross-reacts with epitopically similar autoantigens,2 or immunoreactivity directed against exogenous viral antigens absorbed into the cornea. The concentration of HCV RNA in tear fluid can be higher than that in plasma,4 so the exposure of the ocular surface to a relatively high viral antigen load is possible.
As in any constellation of concurrent clinical findings, the clinician must maintain caution in linking presumptive causes with clinical signs or symptoms. Until the association between HCV and keratitis is either definitively established or found to be coincidental, we recommend that all patients with inflammatory peripheral keratitis without systemic rheumatologic disease be tested for HCV. In cases of suspected staphylococcal marginal keratitis, HCV testing would also be reasonable in atypical presentations or recalcitrant disease.
This study was supported in part by Research to Prevent Blindness, Inc, New York, NY.
Reprints: Keith H. Baratz, MD, Mayo Clinic, 200 First St, SW, Rochester, MN 55902 (e-mail: baratz.keith@mayo.edu).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Archives of Ophthalmology editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 8
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.