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Corneal infiltrates; a rare ocular manifestation in a patient with Crohn's disease

Editor, O cular manifestations in chronic inflammatory bowel disease rarely involve cornea. To the best of our knowledge, there are few reported cases and photographs documenting the clinical course of this ocular complication, and the latest reports were published in 1998 (Chowers et al. 1998; Kodjikian et al. 1998). Here, we present a patient with corneal infiltrates related to Crohn’s disease, successfully treated with topical steroids. In 1980, Knox et al. suggested that two distinct types of keratopathy could be significant clinical signs of Crohn’s disease (Knox, Snip, Stark). The two types were described as epithelial or subepithelial small grey dots in the anterior cornea and deeper lamellar nebulous subepithelial infiltrates. The first type might represent an acute inflammatory response, and the second seems to result from postacute phase scarring (Knox et al. 1980). The corneal manifestations are often bilateral and symmetric, usually located in the inferior pole of the cornea, 2–3 mm from the corneoscleral limbus and rarely impact on the central visual axis (Knox et al. 1980, 1984). The infiltrates with epithelial involvement stain with fluorescein, and the subepithelial infiltrates do not (Knox et al. 1980; Schulman & Sugar 1981; Kodjikian et al. 1998). Crohn’s disease-related keratopathy can be treated with systemic and topical steroids. Our report describes a 15-year-old male, recently diagnosed with Crohn’s disease and referred from the Department of Pediatrics for an ophthalmological examination. The patient had a 2month history of bilateral ocular symptoms that included redness, irritation, mucoid discharge and photophobia. He didnot use contact lenses.The symptoms were most prominent in the right eye. Clinical eye examination revealed uncorrectedvisual acuity (VA)of 1.0/1.1on the Snellen VA chart. Intraocular pressure was 12/14 mmHg by Goldmann applanation tonometry. Slit-lamp examination of the right eye showed mixed injection in the inferior conjunctiva, deep lamellar nebulous subepithelial infiltrates and deep vascularization at the corneoscleral limbus (Figure 1A). No blepharitis, meibomitis, corneal precipitates, fluorescein uptake, acne or rosacea was present. Anterior chamber showed no intraocular reaction. The left eye had normal appearance exceptdiscretemixed injection in the inferior conjunctiva. The combination of Crohn’s disease and the subacute presentation of corneal subepithelial infiltrates of deep lamellar nebulous typewere suspected tobeocular manifestations of inflammatory bowel disease. The patient was prescribed one drop of topical corticosteroids (1 ml/ 1 mg dexamethasone) in the right eye, eight times a day. After one week of treatment, the patient had no symptoms and the slit-lamp examination only showed diffuse scarring and ghost vessels (Figure 1B–C). The following clinical control revealed diffuse corneal opacities. Blepharokeratoconjunctivitis, commonly seen in children, can resemble the described clinical presentation, but patients show signs of blepharitis or meibomitis. Ocular rosacea was neither suspected, due to young age and normal skin condition.Thepatient had ahistory of perioral cold sores, but there were no previous episodes of herpes in the corneal epithelium or stroma. The diagnosis of corneal herpetic keratopathy seemed unlikely as bilateral symptoms of the disease are rarely seen and herpes infections tend to worsen when topical steroids are used without the addition of antiviral drugs. Adenoviral keratoconjunctivitis was also unlikely due to profound localization of the infiltrates and atypical clinical presentation. Patients with Crohn’s disease and ocular manifestations would, in most cases, be referred to an ophthalmologist. The two types of kerathopathy described by Knox et al. almost 40 years ago are important to recognize, as they might be the first clinical sign of