Peripheral Ulcerative Keratitis

Peripheral Ulcerative Keratitis presents with a crescent shaped area of stromal thinning and ulceration of the cornea with an overlying epithelial defect adjacent to the corneal stroma.

It can be associated with an underlying autoimmune disorder. The most common underlying disorders are rheumatoid arthritis, polyarteritis nodosa, inflammatory bowel disease, lupus, relapsing polychrondritis, progressive systemic fibrosis, granulomatosis with polyangiiitis, Churg-Strauss, or microscopic polyangiitis.

Treatment is lubrication, topical antibiotics to prevent a secondary infection, and systemic immunosupression with oral steroids. Cyanoacrylate glue can help in cases of impending perforation. AMT has recently been described to aid in reducing corneal melting in PUK and Mooren's Ulcers.

The first image is an AS-OCT image of a patient with Peripheral Ulcerative Keratitis with 189 microns of residual stroma remaining.  He was then treated with dehydrated  Amniotic Membrane Transplant (AMT).  The amniotic membrane was folded in half and placed under a bandage contact lens.  Several days later it had worked it’s way into the area of stromal thinning, and it has folded on itself multiple times like an accordion

The folded AMT subsequently became incorporated and allowed for epithelialization over the area of thinning. The second AS-OCT image shows 352 microns of AMG incorporated over 131 microns of cornea.

Since that point, his pain and corneal and conjunctival inflammation has resolved and his right eye looks much better.

Active Infection or Quiet Scar?

This is a patient sent for evaluation of a neurotrohic ulcer. The patient had been on Vancomycin, Ciprofloxacin, Loteprednol, Restasis and autologous serum tears in the past and the referring physician was considering re-culturing. Prior cultures were negative per report.

On clinical exam there was no active infection. On AS-OCT, the epithelium is fully intact. The active process likely resolved a while ago, indicated by the significant epithelial hypertrophy. Almost all of the stromal thinning has been filled in. The bright white in the AS-OCT represents the haze of the residual stroma.

Prior history notes perforation of the left eye. It is unclear how this was repaired. In the left eye, there is severe central stromal thinning, with some mild epithelial hypertrophy. 

In the posterior cornea, there appears to be some fibrotic material, possibly iris tissue, which likely had plugged the prior perforation.

Images courtesy of Brett Levinson, MD of Specialized Eye Care.

Epithelial Pooling vs Staining in Dense Central Band Keratopathy

Sometimes it can be difficult to tell the difference between a true epithelial defect versus fluorescein pooling, especially in an eye with dense central band keratopathy.  Fluorescein should not stain intact corneal epithelium. However, in areas of stromal loss or fibrosis, fluorescein can "pool," that is, it can fill the potential space and gives the false impression of true staining.


Here are images of a patient with central band keratopathy with three discrete areas of what appear  to be staining centrally that on first look appeared to be epithelial defects, but are clearly pooling with intact epithelium when viewed with OCT.


A red/ green shift in AS-OCT implies a shift in density.  It is not correlated with a pathological change as in the RNFL reading (green normal, red thin), but rather meant to optically distinguish the layers.

The red in this image highlights the area of band keratopathy and accompanying subepithelial fibrosis and sub-Bowman's anterior stromal haze. There is a remarkable change in density in the anterior stroma

In certain patient's with band keratopathy, Bowman's layer can be eroded. However, the destruction of Bowman's layer varies in patient to patient. The black areas above the red under the intact epithelium represent an optical "shadow" behind an area of extreme density like calcium.

Remember, if AS-OCT is not available to you, one clinical exam trick is to use a sterile cotton swab or weck-cel sponge to wick the excess pooling to either demonstrate intact epithelium or true staining below. In this case, upon wicking away the pooled fluorescein, the epithelium was clinically confirmed to be intact.

Images courtesy of Brett Levinson, MD of Specialized Eye Care.

Abscess and Ulcer Depth

In small circumscribed ulcers, corneal depth can be easily examined with a focal slit-beam. However, when the ulcer is opaque or large and especially when necrotic tissue is present, it can be difficult to judge exact depth of involvement.


This is case of a suture abscess after a 10-0 nylon suture was left after a clear corneal incision after cataract surgery. OCT clearly demonstrates 50% thinning and a full-thickness inflammatory reaction concerning for an impending focal melt and perforation. The angle of the beveled incision is clearly seen.

An older study in the journal Eye (Danjoux JP & Reck AC, 1994) found that ~ 25% patients followed over 3 years had either a loose or broken suture and 45% of these patients were asymptomatic.

Loose or broken sutures must be immediately removed, as flora from the lid and conjunctiva can crawl into the suture tract and form a suture abscess such as the one shown in this case.

Images  courtesy of Brett Levinson, MD of Specialized Eye Care.

Iridocorneal Endothelial Syndrome (ICE) Syndrome

Our inaugural post comes from Brett Levinson, MD of Specialized Eye Care. The images are of a patient in her 30s who noted a triangular shaped left pupil for 2 years which is getting worse. On clinical exam, she has three areas of iris atrophy. Cornea exam was normal. On OCT, there is complete loss of the iris stroma and the residual iris pigment epithelium, and the anterior synechae.

The images are consistent with Essential iris atrophy. This diagnosis is one of three iridocorneal endothelial (ICE) syndromes. Changes affect one eye. Attachments of the iris to the cornea (anterior synechiae) can lead to secondary glaucoma with closure of the angle.