Severe bilateral phlyctenular keratitis secondary to pustular psoriasis, a rare variant of the psoriatic ocular inflammatory disease

Session Details

Session Title: Presented Poster Session: Medical Cornea

Venue: Poster Village: Pod 3

First Author: : J.Fajardo-Sanchez UK

Co Author(s): :    J. Kriman Nuñez   J. Dart                    

Abstract Details

Purpose:

Pustular psoriasis is a rare form of psoriasis comprising approximately 2.2% of all cases, characterized by generalized or localized development of pustules on an erythematous base. The most common ocular manifestations found to be associated with psoriasis are uveitis and blepharitis with dry eye, although is the Psoriatic Arthritis the most frequently associated with these ocular complications. We aim to describe a case of severe bilateral Phlyctenular Keratitis (PK) in a patient diagnosed with Pustular Psoriasis (PP), a rare ocular manifestation that, to the best of our knowledge, has not been yet reported in association with this psoriatic form.

Setting:

Case report of a patient treated at Moorfields Eye Hospital NHS Foundation Trust - Corneal Clinic.

Methods:

A 23-years-old woman with a history of Pustular Psoriasis started with bilateral ocular severe redness, decrease in her visual acuity and swollen eye lids. These ocular manifestations coincided with a psoriatic flare up that developed when she became pregnant. Her corneal appearance consisted in elevated yellow nodules with a central erosion fluorescein positive surrounded by hyperaemic superficial vessels, evenly distributed along the 360 degrees including the visual axis. These findings concur with the presentation of a severe Phlyctenular Keratitis, an ocular phenotype of surface inflammation that does not fit into any description previously reported in association with Pustular psoriasis.

Results:

Our patient did not respond to topical therapy, which included cyclosporine and corticosteroids. In this case, systemic treatment was proposed for the management of the PP as well as the ocular manifestations. Patient was started on Infliximab in 2017, after which the bilateral inflammation and subjective symptoms were reported as solved, with only scars secondary to the bilateral phlyctenular keratitis and ghost vessels remained present. One year later, the patient decided to stop her medication, after which her psoriasis and ocular symptoms flared up again. In this occasion Ixekizumab was started and her symptoms improved once again.

Conclusions:

1. Although the most common ocular findings associated with Psoriasis are uveitis and the blepharitis-dry eye duo, there are other ocular manifestations to consider when assessing a severe inflammatory corneal-ocular surface presentation. Our case reports a bilateral phlyctenular keratitis, a severe manifestation which to the best of our knowledge has not been yet described in association with pustular psoriasis. 2. Patients with systemic inflammatory pathologies and ocular findings could benefit from immunologic therapies, as Infliximab and Ixekizumab, when other less drastic measures (oral tetracyclines, topical steroids in very high doses, and topical Cyclosporine) have been ineffective.

Financial Disclosure:

None