gms | German Medical Science

Keratomalacia, associated with chronic polyarthritis or other connective tissue disorders, often needs complex corneal surgery and systemic immunosuppression. However, despite these therapeutic options complicated cases still remain. TNFα is an important proinflammatory cytokine, which can be detected in the human cornea during keratomalacia. Therefore, use of TNF-alpha-inhibitors seems a reasonable new treatment option.

640 corneal grafts were performed between 1.1.2000 and 15.3.2004. A retrospective analysis could show 26 patients suffering from keratomalacia without evidence of an infectious etiology (cornea culture, Herpes virus PCR, histology). 15 patients suffered from chronic polyarthritis. During follow-up 46 allogeneic keratoplasties were performed. All patients received systemic immunosuppression (prednisolone, methotrexate, cyclophosphamide, cyclosporine A, azathioprine, intravenous immunoglobulins, mycophenolate). Because of unsufficient benefit or contraindication or side effects of systemic immunosuppression seven patients additionally got etanercept and / or infliximab.

19 patients without TNF-alpha inhibitors were sufficiently treated in half of the cases, one patient was enuceated, four died, four retained their eye without visual function. In those 7 patients (4 w, 3 m), additionally treated with etanercept and / or infliximab rapid improvement was detected. They showed impressive reduction of corneal stromal infiltration, clouding and neovascularisation. The sutures became strong, the progressive melting disappeared.

TNF-alpha-inhibitors are an additional, important treatment option with high and rapid efficacy in corneal melting due to rheumatic keratomalacia. It seems reasonable to analyse in further studies, whether TNFα inhibitors should be used as first line drugs in such conditions. Until now optimal dosage and frequency is unclear.