A nursing report on a corneal contact lens wearer receiving keratoplasty due to corneal ulcer and perforation caused by Pythium insidiosum infection: A case report.

BACKGROUND: To report the nursing experience of a case of corneal contact lens wearer receiving the 2nd keratoplasty due to corneal ulcer and perforation caused by Pythium insidiosum infection. METHODS: A 30-year-old female patient had blurred vision after deep anterior lamellar keratoplasty for a right corneal ulcer. At the 5th week, the right eye appeared the symptoms, such as redness and pain. The anterior segment photography was performed on the eye, and the result showed that the epithelium was missing in the right eye lesion area, and a large number of longitudinal and transversal streaks were visible from the epithelium to the stroma, with fungus filaments to be discharged. Upon macro-genome sequencing of the corneal secretion, a P. insidiosum infection was observed. Then, the patient underwent the keratoplasty, and 3 weeks later, the corneal implant showed a tendency to dissolve, the sutures were partially loosened, and the eye was almost blind. Subsequently, the patient was admitted to our hospital and subject to the 2nd penetrating keratoplasty of the right eye (allograft). After surgery, linezolid and azithromycin injections were given through intravenous drip and local drip of the eye for anti-inflammation, and tacrolimus eye drops for antirejection. RESULTS: Postoperatively, the patient showed signs of recovery with slight corneal edema and visible pupil, leading to discharge with improved vision. The corneal implant was normal 1 week after surgery and the vision of the right eye was hand move/before eye at the 6th month of follow-up. Continuous care and removal of sutures 3 months post-surgery contributed to a successful outcome, with the patient achieving hand motion vision 6 months after the procedure. CONCLUSION: Corneal ulcer caused by P. insidiosum infection not only needs timely and effective keratoplasty intervention, but also requires perfect nursing measures.

[A case of bilateral corneal ulcer after left eye cataract extraction surgery].

The patient is a 73-year-old female who developed bilateral corneal ulcers one month after cataract surgery in her left eye. The diagnosis is bilateral conjunctival pemphigoid. She underwent a left-eye amniotic membrane transplant and a right-eye lamellar corneal transplant, and was treated with oral immunosuppressants. The patient's condition is stable.

A stitch in time saves my (ne) (vision).

Background: Corneal melt with iris prolapse is a rare complication of autoimmune diseases, especially rheumatoid arthritis. Purpose: To highlight a challenging case of a peripheral ulcerative keratitis (PUK) with corneal melt and iris prolapse in a patient's only eye. Synopsis: A 56-year-old Asian Indian male presented with blurring of vision in the right eye and was diagnosed with cataract. He was a known type 2 diabetes mellitus and a rheumatoid arthritis patient and was not on treatment. He had been previously diagnosed with PUK in the left eye and was lost to follow-up due to coronavirus disease 2019 (COVID-19) after therapeutic penetrating keratoplasty and lost his vision in that eye. Cataract surgery in the right eye was done under cover of immunosuppression. Subsequently, he developed PUK and was treated with a glue and bandage contact lens. Again, he was lost to follow-up and then presented a few months later with corneal melt with iris prolapse in the right eye. We describe in the video the surgical and medical challenges and successful salvage of both the eyeball and the vision. Highlights: Highlights include the following: 1. A rare case of corneal melt with iris prolapse. 2. Demonstration of surgical technique of patch graft. 3. Anterior segment optical coherence tomography before and after the procedure. Video link: https://youtu.be/HbgixlEAYKU.

Pyogenic granuloma of the cornea in a pony: Uncommon complication of corneal wound healing.

A 6-year-old miniature Shetland pony mare was referred for evaluation of a left corneal mass, which developed from the healing tissue of a corneal traumatic ulceration that had occurred 4 weeks previously. On gross examination, a spherical, smooth-surfaced, and pink-colored lesion of about 1 cm in diameter was protruding from the left palpebral fissure. Ophthalmic examination revealed that it was attached to the scar tissue of the cornea, and that one corpora nigra was adherent to the posterior face of corneal wounded area, without sign of uveitis. The remainder of the ophthalmic examination was unremarkable. The mass was excised, and cryotherapy was used as an adjunctive therapy. Histopathology of the resected mass was consistent with a pyogenic granuloma on the basis of radially oriented proliferating capillaries, embedded in immature granulation tissue containing an infiltrate of neutrophils, plasma cells and eosinophils. There were no histological features of malignancy. 2 months after surgery, the ventral part of the fibrotic corneal scar was slightly raised by a pink tissue, suggesting possible recurrence of the initial lesion. A second cryotherapy was performed over the leukoma area. No recurrence has been noted for a follow-up period of more than 25 months. Pyogenic granuloma is a benign proliferative fibrovascular response that typically develops after trauma or surgery. Corneal involvement is rare in humans, and to the authors' knowledge has never been documented in veterinary ophthalmology.

Clinical Manifestations of Monkeypox.

Monkeypox is a global health issue caused by the monkeypox virus. It can spread from person to person through respiratory secretions, direct exposure to dermatological lesions of infected patients, or exposure to contaminated objects. It is more common in homosexual men, and most patients are asymptomatic. The gold standard for diagnosis is a real-time polymerase chain reaction. In the absence of testing facilities, clinicians rely upon detailed history to exclude other causes of fever with rashes. Initially, there is a prodrome phase of a few days, which is followed by the appearance of rashes. The dermatological manifestations are in the form of an exanthematous rash, which transforms through a macular, papular, and vesicular phase and disappears after crusting in approximately 3 weeks. There can be associated lymphadenopathy in these patients. Respiratory manifestations include nasal congestion and shortness of breath that may result in secondary bacterial infections. Additionally, patients can have neurological involvement in the form of encephalitis. Furthermore, ocular involvement can occur in the form of conjunctivitis, keratitis, and corneal ulceration. Other symptoms can include diarrhea, vomiting, myalgia, and backache. Since most patients do not require hospitalization, the approach to treatment is mainly vigilant monitoring, antiviral therapy, and management of associated complications.

Peripheral ulcerative keratitis, nodular episcleritis, and pulmonary nodules as the initial signs of rheumatic arthritis: A Case Report.

Background: Rheumatoid vasculitis (RV) is a rare but potentially devastating complication of rheumatoid arthritis (RA). It typically occurs in patients with extra-articular manifestations. Here we reported a case of PUK with nodular episcleritis and pulmonary nodules that occurred in the same patient without joint involvement. Case presentation: A 43-year-old Chinese woman, exhibited a partial crescent-shaped marginal corneal ulcer in the right eye at admission and the ulcer developed rapidly into nearly 360-degree ulcers in both eyes within one week. Nodular episcleritis was observed in the right eye. Conjunctival biopsy revealed vasculitis. Her rheumatoid factor (RF) and anti-cyclic citrullinated protein antibody were positive, while anti-neutrophilic cytoplasmic antibody (c-ANCA) and anti-protease 3 were negative. Pulmonary nodules were found, without joint involvement. The ocular condition did not relieve under the topical and systemic use of corticosteroids, or under other immunosuppressive agents until the infliximab therapy. PUK recurrence was observed after the discontinuation of infliximab. Conclusions: Rapidly deteriorated PUK with nodular episcleritis and pulmonary nodules occurred in the same patient is a special case of RA without joint involvement. This case reinforces the concept that RV may be the initial sign of RA. Infliximab can be used to prevent further progress of RA-related PUK in some refractory cases.

Peripheral ulcerative keratitis due to systemic diseases.

PURPOSE OF REVIEW: To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases. RECENT FINDINGS: Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death. SUMMARY: Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.

[The prevention and therapy of corneal ulcers in patients with large-area thermal burns].

Objective: To evaluate the characteristics of ocular injury in patients with severe extensive thermal burns, and to explore the effective methods to prevent and treat corneal ulcers related to severe burns. Methods: A retrospective case series study. Between 2010 and 2019, Sixteen severe thermal burn patients with burn sizes>70% of the total body surface area involving the ocular region were admitted to the Burns and Plastic Surgery Division of Chinese PLA General Hospital, and consult with Ophthalmology Division. There were deep second-degree to fourth-degree burns in the eyelids. In the eleven surviving patients, 22 eyes presented ectropion. Eyelid full-thickness skin grafting (EFTSG) combined with or without tarsorrhaphy was performed in 20 eyes due to severe corneal exposure. Two eyes received partial blepharorrhaphy because of mild ectropion. The ocular manifestations and treatment outcomes were reviewed and assessed. Results: The majority of the patients were youth, and the average age was (36.8±10.4) years. The burn area was 84.0%±9.1% of the body surface area. Corneal ulcers secondary to lagophthalmos occurred at (35.1±15.6) days after burning in 75% (24/32) of eyes. Perforation was found in 18.8% (6/32) of eyes. Among the 22 operated eyes, the corneal ulcer was repaired in all 9 eyes receiving EFTSG with tarsorrhaphy, whereas ectropion recurred in 8 of 11 eyes only receiving EFTSG, and 4 eyes underwent further surgery due to corneal epithelial defects. Conclusions: In patients with severe large-area thermal burns, corneal ulcers are common complications. Prevention of corneal exposure is vital because the treatment of corneal ulceration is difficult due to eyelid deformity, inflammation and the absence of donor skin. Timely full-thickness skin grafting and blepharorrhaphy are effective approaches to preventing exposure keratopathy. To severe ulcers occur, conjunctival flap or Tenon's capsule covering combined with eyelid EFTSG and tarsorrhaphy is useful to rescue visual function.

Corneal complications of rheumatoid arthritis.

PURPOSE OF REVIEW: Rheumatoid arthritis (RA) is an autoimmune disease that primarily affects the joints. Extra-articular manifestations (EAMs) are common and may affect up to 40.6% of patients. Ocular EAM can occur in 39% of the patients. The cornea is involved by different pathogenic mechanisms and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss. Severe corneal involvement is associated with increased mortality in RA patients. We aimed to review the prevalence, mechanisms, management and overall impact of corneal involvement in RA patients. RECENT FINDINGS: Corneal involvement is frequent among RA patients. With the wider use of systemic immunosuppression, in particular the disease-modifying antirheumatic drugs (DMARDs), and with improvement of surgical techniques, spontaneous and surgery-related corneal ulceration and melting is becoming less common. However, RA patients are still at risk and should be carefully managed. SUMMARY: RA-related corneal complications are associated with a decreased quality of life and poor ocular and systemic prognosis. Prompt recognition and a multidisciplinary approach involving topical ophthalmic management and systemic immunosuppression are the key factors to maintain ocular integrity and avoid a lethal outcome.

Incidence and risk factors for post-penetrating keratoplasty glaucoma.

Purpose: To carry out a prospective study to analyze the incidence and various preoperative, intraoperative, and postoperative risk factors for the development of PPKG. Methods: A total of 207 patients were analyzed prospectively, who were operated for penetrating keratoplasty (PK) in a tertiary eye care hospital between the time period of August 1, 2017 and February 28, 2018 and were followed up till the sixth month. Each patient was analyzed at every visit to determine the factors responsible for post-keratoplasty glaucoma. Results: Out of 207 eyes, post-PK glaucoma developed in 84 cases, which yielded an incidence of 41%. Incidence of PPKG (Post PK glaucoma) in various conditions was as follows: in repeat PK 62%, in perforated corneal ulcer 33%, in nonperforated corneal ulcer 29%, in corneal scar including adherent leukoma 37.2%, and in pseudophakic bullous keratopathy and aphakic bullous keratopathy, 14% and 80%, respectively. In age- and sex-adjusted multivariate analysis, the significant risk factors were age (P-value- 0.006), presence of PAS (P-value 0.001), and fellow eye glaucoma (P-value 0.04). Aphakia and combined surgery were not found to be significant. Conclusion: Our study recommends a meticulous examination of the fellow eye to assess the presence of glaucoma as it can increase the suspicion of glaucoma in the eye to be operated. The presence of PAS and age are important risk factors for developing PPKG. The risk of developing PPKG increases exponentially as the number of risk factors increases, but the presence of more than three risk factors does not add to the development of PPKG.

Peripheral ulcerative keratitis as presenting manifestation of systemic microscopic polyangiitis: a case report.

Microscopic polyangiitis is a rare autoimmune disease of unknown etiology, characterized by inflammation and necrosis of blood vessels. It forms a part of the antineutrophil cytoplasmic antibody-associated vasculitides-a heterogeneous group of disorders characterized by vasculitis. It is a systemic disease affecting multiple organs. The patients may present with a wide variety of symptoms. Ocular manifestations may present as its initial clinical symptoms, necessitating a multidisciplinary approach for reducing the morbidity and mortality. Early diagnosis aids in the formulation of appropriate treatment and prevention of further complications. Aggressive treatment, including surgery, is often necessary to limit structural damage and preserve visual function. We present the case of an 82-year-old woman who initially presented with peripheral ulcerative keratitis that led to the diagnosis of microscopic polyangiitis.

Corneal perforation due to vitamin A deficiency in a patient with short bowel syndrome.

A 55-year-old Caucasian woman presented with a 1-week history of left eye redness and blurred vision. Her medical history included previous small bowel resection and ileostomy for ischaemic bowel. Ophthalmic examination revealed a left corneal ulcer requiring hospital admission for intensive topical antibiotics. Overnight she became systemically unwell and was diagnosed with urinary tract infection requiring intravenous antibiotics. Her corneal condition deteriorated resulting in corneal perforation, which required a surgical gluing procedure. Despite surgery, the cornea perforated on two further occasions. At this stage, vitamin A deficiency (VAD) was suspected, due to the corneal melting response that was occurring. VAD was subsequently confirmed by serology and had occurred in this case due to malabsorption as a result of short bowel syndrome caused by previous small bowel surgery. The patient was treated with intramuscular vitamin A and eventually made a good visual and systemic recovery.

Ozonoterapia como tratamiento coadyuvante en la úlcera corneal grave bacteriana / Ozone therapy as adjunctive treatment in severe bacterial corneal ulcer / Ozonoterapia como tratamento adjuvante em úlcera bacteriana da córnea grave

Introducción: La evolución espontánea o los casos mal tratados de la úlcera corneal conllevan el riesgo de extensión de la infección, con severa afectación visual e integridad estructural del ojo. Objetivo: Describir las características clínico-epidemiológicas de pacientes con úlcera corneal grave bacteriana tratada con ozonoterapia local coadyuvante al tratamiento protocolizado. Método: Se realizó un estudio observacional, descriptivo y transversal con 48 pacientes ingresados en el servicio de Oftalmología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", de Santiago de Cuba, en el periodo de enero de 2017 a diciembre de 2019. Las variables del estudio fueron: edad, sexo, factores predisponentes, microorganismos, signos de mejoría clínica, resultados al tratamiento y complicaciones. Para la validación estadística se utilizó prueba Chi-cuadrado. Resultados: La edad promedio de los pacientes fue de 54,1 años, el 62,5 % eran hombres. Predominó el trauma ocular (63,3 %) en el sexo masculino y enfermedades oculares (44,4 %) en el femenino. La mejoría de los signos fue más representativa a los 14 días. Se logró resultados satisfactorios en el 100 % de los pacientes con microorganismos grampositivos. El 10,4 % presentó perforación corneal. Conclusiones: La ozonoterapia es una terapia válida como tratamiento en la úlcera corneal grave de etiología bacteriana y responde a la búsqueda de alternativas para pacientes con resistencia a los tratamientos antibacterianos que se ofertan en el cuadro básico de salud.

ABSTRACT Introduction: Spontaneous evolution or poorly treated cases of corneal ulcer carry the risk of extension of the infection, with severe visual impairment and damage to the structural integrity of the eye. Objective: To describe the clinical-epidemiological characteristics of patients with severe bacterial corneal ulcer treated with local ozone therapy as an adjunct to the standard protocol treatment. Method: An observational, descriptive and cross-sectional study was carried out on 48 patients admitted to the Ophthalmology service of the Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", from Santiago de Cuba, in the period from January 2017 to December 2019. The study variables were: age, gender, predisposing factors, microorganisms, signs of clinical improvement, treatment results and complications. Chi-square test was used for statistical validation. Results: The average age of the patients was 54.1 years; 62.5% of them were men. Ocular trauma (63.3%) predominated in males, and ocular diseases (44.4%) in females. The improvement of the signs was more common after 14 days. Satisfactory results were achieved in 100% of patients with gram-positive organisms. 10.4% presented corneal perforation. Conclusions: Ozone therapy is valid as a treatment for severe corneal ulcer of bacterial etiology, and responds to the search for alternatives for patients with resistance to the antibacterial treatments that are offered in the basic health system.

RESUMO Introdução: A evolução espontânea ou casos mal tratados de úlcera de córnea trazem o risco de extensão da infecção, com comprometimento visual grave e integridade estrutural do olho. Objetivo: Descrever as características clínico-epidemiológicas de pacientes com úlcera bacteriana de córnea grave tratados com ozonioterapia local como coadjuvante ao tratamento protocolizado. Método: Foi realizado um estudo observacional, descritivo e transversal com 48 pacientes internados no serviço de Oftalmologia do Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", de Santiago de Cuba, no período de janeiro de 2017 a dezembro de 2019. As variáveis do estudo foram: idade, sexo, fatores predisponentes, microrganismos, sinais de melhora clínica, resultados do tratamento e complicações. O teste do qui-quadrado foi usado para validação estatística. Resultados: A idade média dos pacientes foi de 54,1 anos, 62,5% eram homens. O trauma ocular (63,3%) predominou no sexo masculino e as doenças oculares (44,4%) no feminino. A melhoria da sinalização foi mais representativa aos 14 dias. Resultados satisfatórios foram alcançados em 100% dos pacientes com organismos gram-positivos. 10,4% apresentaram perfuração corneana. Conclusões: A ozonioterapia é uma terapia válida como tratamento para úlcera de córnea grave de etiologia bacteriana e responde à busca de alternativas para pacientes com resistência aos tratamentos antibacterianos que são oferecidos no quadro básico de saúde.

Low-Concentration (0.66%) Povidone Iodine Treatment of a Corneal Ulcer in a Rheumatoid Arthritis Patient.

BACKGROUND Peripheral ulcerative keratitis is one of the ocular complications associated with chronic inflammatory immune-mediated diseases, such as rheumatoid arthritis, in which inflammatory reactions and infections can be recurrent. Suspected infections are treated with topical antibiotics that, in some cases, may promote selection of resistant microbes. Povidone iodine is known for its rapid broad-spectrum activity against all kinds of microbes and biofilms, lack of microbial resistance, ability to counteract excessive inflammation, and efficacy in wound healing, along with an optimum safety and tolerability profile. The purpose of this case report is to show the resolution of a peripheral ulcerative keratitis case by means of treatment with 0.66% povidone iodine. CASE REPORT An 89-year-old woman with rheumatoid arthritis, 1 eye, and a superior descemetic corneal ulcer was treated with amniotic membrane, topical antibiotics, and antiviral drugs without any control of clinical signs and symptoms. Therefore, all anti-infective treatments were replaced with 0.66% povidone iodine (3 times/day) given alone for 5 weeks and then associated with serum eyedrops. When a clear regression of the ulcer was observed, the patient was maintained with serum eyedrops only. CONCLUSIONS Unusual treatment with povidone iodine 0.66% (used for the first time in an autoimmune patient), alone and in association with serum eyedrops, probably contributed to alleviate the signs and symptoms of a case of peripheral ulcerative keratitis not responding to conventional treatments. Although its regular use warrants further investigation, povidone iodine seems a useful therapeutic tool for the treatment of corneal ulcers associated with chronic immune-mediated inflammatory diseases.

Efficacy and safety of rituximab in peripheral ulcerative keratitis associated with rheumatoid arthritis.

OBJECTIVE: Peripheral ulcerative keratitis (PUK) is a rare but severe ocular complication of rheumatoid arthritis (RA). It can be considered as an ocular manifestation of rheumatoid vasculitis (RV). Our case series aimed to evaluate the efficacy of rituximab (RTX) for PUK occurring in patients with RA. METHODS: Study population were patients with RA-associated PUK treated with RTX 1000 mg on days 1 and 15 at least once after the diagnosis. We identified patients referred to the rheumatology and ophthalmology departments of our hospital between February 2014 and June 2020. We also included patients referred by their specialist after being contacted through the Club Rhumatismes et Inflammation. Demographic data and clinical and biological features were retrospectively collected. RESULTS: We included seven patients (three men and four women, median age 58 years). All but one had a long-standing RA with a median disease duration of 13.9 years (IQR 0-30.2). RA was erosive in six out of seven patients. All patients had rheumatoid factors and anticitrullinated peptides antibodies were positive in six of them. PUK was complicated by corneal perforation in three patients and required surgery. After a median follow-up of 29.8 months (IQR 5-75), corneal inflammation was controlled in all patients. PUK recurred in one patient, 8 months after a single infusion of RTX. 71% of the patients presented a good articular response. No patient developed other manifestations of RV. No serious adverse event related to RTX was observed. CONCLUSION: RTX appears to be an efficient and safe therapeutic option in the treatment of RA-associated PUK.

[A clinical analysis of 46 cases of neurotrophic keratitis].

Objective: To investigate the clinical characteristics and therapeutic effect of neurotrophic keratitis (NK). Methods: A retrospective case series study. A total of 46 patients (48 eyes) with clinically diagnosed NK in Beijing Tongren Hospital from May 2013 to July 2016 were analyzed, including 26 males (26 eyes) and 20 females (22 eyes), aged (51±18) years. The general condition, etiology, clinical features, stage of disease and curative effect of NK patients were summarized. Corneal sensation was measured by Cochet-Bonnet corneal sensor for 25 patients (26 eyes), and the correlation between corneal sensation and clinical staging was analyzed. The χ(2) test was performed on the distribution characteristics of patients with different clinical stages of NK. Correlation analysis of corneal sensation and the disease stage was performed using Spearman correlation analysis. Results: Forty-four cases of monocular disease (96.65%) and 2 cases (4.35%) of bilateral disease were enrolled. Four eyes (8.33%) were from young patients (aged 18-29 years), 23 (47.92%) were from middle-aged patients (aged 30-59 years), and 21 (43.75%) were from elderly patients (aged ≥60 years). The disease was at stage Ⅰ in 8 eyes (16.67%), at stage Ⅱ in 21 eyes (43.75%), and stage Ⅲ in 19 eyes (39.58%). There was no significant difference in clinical staging between the three age groups (χ(2)=2.452, P=0.658). The most common cause of NK was virus infection (17 eyes,35.42%), followed by neurosurgical sequelae (11 eyes, 22.92%) and diabetes in 10 eyes(20.83%). Corneal sensation of 26 eyes ranged from 0-3 cm. There was no significant correlation between clinical stage and corneal sensation (r(2)=0.284, P=0.753). The patients were followed up for an average of 7 months. Thirty-four eyes (70.83%) received conservative treatment, and 8 eyes(16.67%) had surgery. Six patients (6 eyes) were lost for follow-up. Conclusions: NK can occur in all ages, mainly in the elderly. The clinical manifestations are diverse. If time delays in the diagnosis and treatment, it often causes corneal ulcers. There is no significant correlation between corneal sensation and clinical stage. Early diagnosis and targeted treatment are important for protecting patients' visual function.(Chin J Ophthalmol, 2020, 56:274-298).

Peripheral Ulcerative Keratitis Secondary to Atypical Hemolytic Uremic Syndrome.

PURPOSE: To report a case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. METHODS: We report the case of a 76-year-old man who presented with bilateral aggressive peripheral ulcerative keratitis. Clinical examinations and investigations are reported from the patients' admission. RESULTS: The patient had an extended workup for autoimmune and infectious etiologies that all returned negative. The laboratory work in conjunction with renal biopsy and clinical symptoms were consistent with atypical hemolytic uremic syndrome. The patient was treated with systemic steroids for his peripheral ulcerative keratitis and underlying systemic disease. Corneal glueing and amniotic membrane grafting was also performed. CONCLUSIONS: To our knowledge, we report the first known case of peripheral ulcerative keratitis secondary to atypical hemolytic uremic syndrome. In cases where the standard workup is negative, this diagnosis should be considered because it can have significant systemic morbidity.