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Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 102-104

Bilateral disciform keratitis: A rare feature of Reiter's syndrome

Department of Ophthalmology, Bharati Hospital and Research Centre, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India

Date of Submission16-Apr-2014
Date of Acceptance04-Nov-2014
Date of Web Publication7-May-2015

Correspondence Address:
Tejaswini P Khandgave
New Staff Quarters, Bharati Vidyapeeth Campus, Bharati Vidyapeeth Deemed University Medical College, Dhankawadi, Pune - 411 043, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3897.156605

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Reiter's syndrome is a relatively rare seronegative spondyloarthropathy characterized by a triad of urethritis, arthritis, and conjunctivitis. Human leukocyte antigen B27 (HLA B27) is positive in over two-thirds of the patients. Involvement of the cornea in the form of a bilateral disciform keratitis in a first episode of Reiter's is an extremely rare feature, with only one previous report. Other report indicates the occurrence of disciform keratitis in patients with chronic recurring episodes of Reiter's syndrome. We report acase of a young girl who developed bilateral disciform keratitis against a clinical background of arthritis of the left knee. There was preceding history of acute infective diarrhea, 1 month earlier. Initially, the keratitis was thought to be viral, but response to antiviral treatment was poor. A clinical suspicion of Reiter's syndrome was confirmed by a positive HLA B27 test. Definitive treatment with steroids and sulfasalazine resulted in resolution of the keratitis.

Keywords: Disciform keratitis, HLA B27, reiter′s syndrome

How to cite this article:
Khandgave TP, Puthran N, Kulkarni VN. Bilateral disciform keratitis: A rare feature of Reiter's syndrome . J Clin Ophthalmol Res 2015;3:102-4

How to cite this URL:
Khandgave TP, Puthran N, Kulkarni VN. Bilateral disciform keratitis: A rare feature of Reiter's syndrome . J Clin Ophthalmol Res [serial online] 2015 [cited 2023 Jun 2];3:102-4. Available from: https://www.jcor.in/text.asp?2015/3/2/102/156605

Reiter's syndrome is a seronegative spondyloarthropathy characterized by triad of urethritis, arthritis, and conjunctivitis. It is generally preceded by either a chlamydial genitourinary infection, or an enteric infection by Shigella, Campylobacter, or Salmonella. [1] Incidence of Reiter's syndrome is estimated to be 3.5 in 1,00,000 population. [2] Disciform keratitis is a rare feature of Reiter's syndrome.

  Case Report Top

A 13-year-old girl was being treated for painful swelling of the left knee, with pain in the toes of the right foot, 15 days prior to developing ocular complaints. There was preceding history of an episode of diarrhea and fever about a month earlier. The painful joints were also accompanied by fever. The patient underwent aspiration of synovial fluid left knee. Gram-positive cocci were seen on smear, although bacterial culture was negative. She was treated with systemic antibiotics and anti-inflammatory drugs.

The patient presented to the ophthalmic outpatient department (OPD) with diminished vision, photophobia, and a painful red right eye of 3-days duration. Vision in the right eye was reduced to finger counting close to face and a large epithelial defect (9 mm × 8 mm) with ragged margins and underlying disciform stromal edema was noted. There were dense multifocal infiltrations at the border of the defect along with endothelial plaques and a small hypopyon [Figure 1]. Corneal sensations were diminished over uninvolved corneal area. Intraocular pressure was normal. The dense stromal haze precluded visualization of posterior structures. The left eye was normal.
Figure 1: Disciform keratitis with epithelial defect, endothelial plaque, and hypopyon (right eye)

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Corneal scrapings for Gram's stain, potassium hydroxide (KOH) as well as for bacterial and fungal cultures were all negative. Topical treatment with 0.5% moxifloxacin eight times a day, 3% acyclovir five times a day, 1% atropine three times daily, and 1% carboxy methylcellulose was instituted along with oral Valcyclovir 500 mg three times daily. The hypopyon and epithelial defect healed, but stromal edema remained unaltered.

Within 72 hours, the left eye also developed a similar epithelial defect (5 mm × 4 mm) with ragged margins with endothelial plaques, and disciform stromal edema in the central cornea with dense multifocal infiltrations at the periphery of the defect with reduced corneal sensations.

Vision was reduced to finger counting at 3 meters [Figure 2]. Patient was started on similar treatment in left eye. Following corneal epithelial healing, patient was put on topical prednisolone acetate four times a day for both eyes considering viral disciform keratitis.
Figure 2: Disciform keratitis with epithelial defect, endothelial plaque (left eye)

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In view of the concurrent arthritis a rheumatological work-up was ordered which showed a raised erythrocyte sedimentation rate (ESR) (53 mm), raised C-reactive protein (CRP) (23IU), and a raised platelet count (6.37 lacs/mm3). Other tests such as rheumatoid arthritis (RA) factor, antinuclear antibodies (ANA), anti-cyclic citrullinated peptide antibody, and human immunodeficiency virus (HIV) were negative. A positive human leukocyte antigen B27 (HLA B27) confirmed the diagnosis of Reiter's reactive arthritis. Patient was treated with oral sulfasalazine, oral prednisolone acetate, and supportive therapy for 1 month.

The bilateral keratitis resolved partially but rapidly in 5 days time [Figure 3] and [Figure 4]. Complete resolution took 4 weeks when all medications were stopped. Presently, the patient has a small residual nebular corneal opacity in the right eye with visual acuity of 6/6 in each eye.
Figure 3: Resolving keratitis (right eye)

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Figure 4: Resolving keratitis (left eye)

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  Discussion Top

Reiter's syndrome generally occurs in the second to fourth decades of life, occurring 1 to 4 weeks after a genitourinary infection (male to female ratio 9:1) or an enteric infection (male to female ratio 1:1). [3] Bacterial antigens persisting within the synovial and other tissues, stimulate a proliferative T-cell response which eventually targets autoantigens, causing inflammation and tissue destruction. Reiter's syndrome is associated with HLA B27 in approximately 75-90% of the patients. [3]

Ocular manifestations include conjunctivitis (96%) and anterior uveitis (92%), while rare ocular involvements are posterior uveitis (64%), scleritis (28%), cataract (56%), glaucoma (16%), papillitis (16%), retinal and disc edema, and retinal vasculitis. [4],[5] Keratitis is rarely seen during a first attack, but has been reported in 64% patients with recurrent episodes of Reiter's syndrome. [4] The keratitis may be in the form of superficial punctate keratitis with pleomorphic anterior stromal infiltrates, [5] deep interstitial keratitis, [6] anterior stromal infiltrations with epithelial defect. [7] Kiss et al.[4] reported keratitis in 16 out of 25 patients with chronic Reiter's syndrome, but did not describe details of morphology.

To the best of our knowledge only two authors [8],[9] have reported disciform keratitis in patients with Reiter's syndrome, one occurring during the first episode of the syndrome [8] while the other developing in chronic recurrent Reiter's syndrome. [9]

Mark and McCulley [9] described left eye disciform keratitis with hypopyon in one case with chronic Reiter syndrome. Unilateral disciform keratitis developed a month after anterior stromal keratitis and epithelial defect in that eye. It was attributed to immunological reaction to Chlamydial antigen. Our patient showed no bacteria or fungus on smear and culture of corneal scrapping.

Suresh PS [8] reported a case of bilateral disciform keratitis with hypopyon in the left eye occuring during first episode of Reiter's syndrome. The hypopyon was attributed to a presumed secondary bacterial infection. Our patient had similar bilateral disciform keratitis with epithelial defects, with hypopyon in right eye. The large endothelial plaques and reduced corneal sensations in our patient have not, so far, been reported in Reiter's syndrome.

In view of reduced sensations, disciform keratitis, a viral etiology was first considered. A likely fungal etiology, suggested by epithelial defect with multifocal infiltrations, endothelial plaques, and hypopyon, was excluded by negative KOH and fungal culture. The patient was treated with topical and systemic antiviral drugs along with prophylactic antibiotics. Despite this, the stromal keratitis did not improve, although the hypopyon and epithelial defect disappeared. Following receipt of the positive HLA B 27 report, our patient who was already on topical steroids after epithelial defect healed, was started on systemic prednisolone acetate 40 mg a day tapered over 4 weeks and systemic sulfasalazine 500 mg twice a day and she recovered completely within 4 weeks. Many cases respond well to systemic prednisolone. [4]

To the best of our knowledge, this is the second case report of bilateral disciform keratitis occurring during an initial episode of Reiter's syndrome. This case highlights the importance of considering diagnosis of Reiter' syndrome in patients with arthritis along with bilateral disciform keratitis with reduced corneal sensations.

  Acknowledgement Top

Dr. Sanjay Patil, Prof and HOD, Department of Orthopedics, Bharati hospital and research Centre, BVDUMC, Pune. Dr. Kavita Krishnan, Rheumatologist, Department of Medicine, Bharati hospital and research Centre, BVDUMC, Pune.

  References Top

Toivanen P. Managing reactive arthritis. Rheumatology (Oxford) 2000;39:117-9.  Back to cited text no. 1
Kirchner JT. Reiter's syndrome. A possibility in patients with reactive arthritis. Postgrad Med 1995;97:111-2, 115-7, 121-2.  Back to cited text no. 2
Keat A. Reiter's syndrome and reactive arthritis in perspective. N Eng J Med 1988;309:1606-15.  Back to cited text no. 3
Kiss S, Letko E, Qamruddin S, Baltatzis S, Foster CS. Long term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter's syndrome. Ophthalmology 2003;110:1764-9.  Back to cited text no. 4
Lee DA, Barker SM, Su WP, Allen GL, Liesegang TJ, Ustrup DM. The clinical diagnosis of Reiter's syndrome. Ophthalmic and nonophthalmic aspects. Ophthalmology 1986;93:350-6.  Back to cited text no. 5
CASS EE. Interstitial keratitis occurring in a case of Reiter's disease. Br J Ophthalmol 1949;33:454.  Back to cited text no. 6
Rowson NJ, Dart JK. Keratitis in Reiter's syndrome. Br J Ophthalmol 1992;76:126.  Back to cited text no. 7
Suresh PS. Bilateral disciform keratitis in Reiter's syndrome. Indian J Ophthalmol 2013.  Back to cited text no. 8
Mark DB, McCully JB. Reiter's keratitis. Arch Ophthalmol 1982;100:781-4.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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