Bilateral punctate keratitis and hurricane keratopathy following apremilast therapy

Abstract

Purpose: To report a unique case of bilateral punctate keratitis consistent with hurricane keratopathy during apremilast therapy.

Observations: A 49-year-old female presented with severe, painful, bilateral, punctate keratitis following five months of apremilast therapy. The past ocular history was noncontributory. The past medical history included psoriasis refractory to topical corticosteroids. The patient subsequently received systemic apremilast therapy and noted improvement in her psoriatic rash. Five months later the patient presented to an outside eye care provider complaining of three weeks of progressive photophobia associated with pain and redness in both eyes. On examination, the patient had decreased visual acuity with diffuse conjunctival injection and punctate epithelial erosions in a whorl-like pattern in both eyes. The remainder of the ophthalmic exam was unremarkable. The patient was started on topical moxifloxacin drops, erythromycin ointment, and preservative free artificial tears, but did not improve. Apremilast was then discontinued and topical prednisolone was added once per day. Ten weeks after discontinuation of apremilast and topical steroid therapy, the patient had recovered normal vision with an intact and normal corneal epithelium.

Conclusions and importance: This is the first case report of cornea epithelial keratitis resembling hurricane keratopathy associated with apremilast treatment and should be recognized as a possible side effect of therapy with this class of drug.

Keywords: Adverse drug reaction; Anti-inflammatory; Apremilast; Corneal epitheliopathy; Cytotoxicity; Hurricane keratopathy.

Fig. 1

Slit lamp photographs at initial presentation. In (A) and (B), representing OD and OS respectively, a whorl-like pattern of opacity is seen in each cornea. Subsequent staining with fluorescein as shown in (C) and (D), representing OD and OS respectively, highlights these distributions of dense, punctate epithelial erosions in each eye.

Fig. 2

Slit lamp exam with slit beam demonstrating level of involvement limited to epithelium without associated stromal involvement.

Fig. 3

Slit lamp photographs at follow-up examination 10 weeks after discontinuation of apremilast therapy. (A and C: OD; B and D: OS). Both corneas were free of opacity (A and B), and were negative for fluorescein staining (C and D).