Case highlights a rare overlap of peripheral ulcerative keratitis and neurotrophic keratitis
At SECO 2026, Amanda Eslinger, OD, et al presented a complex case illustrating the diagnostic and management challenges of peripheral ulcerative keratitis (PUK) with concurrent neurotrophic keratitis (NK).
The case involved an 86-year-old White woman who presented with redness, tearing, and blurred vision in the right eye. Slit lamp examination revealed severe peripheral corneal thinning. Corneal cultures were negative, confirming a sterile ulcer and supporting a diagnosis of PUK, likely associated with the patient’s underlying polymyalgia rheumatica (PMR). Despite the severity of the corneal findings, the patient reported only mild discomfort, raising concern for overlapping NK.
Further evaluation demonstrated reduced corneal sensation, confirming NK in addition to PUK. The patient had been seen less than two months earlier for a routine glaucoma visit with no corneal abnormalities, making the rapid onset of thinning a significant clinical concern. She denied trauma. Review of systemic history revealed long-term prednisone use for PMR; due to a medication error, she had been receiving a lower dose than prescribed for more than a month prior to symptom onset. Her primary care physician was contacted to address this issue.
The differential diagnosis included Mooren’s ulcer, viral keratitis, and marginal keratitis, each considered less consistent with the patient’s presentation based on pain level, clinical pattern, and systemic associations. Diagnosis of NK relied on clinical findings, particularly decreased corneal sensation, emphasizing the importance of testing corneal sensitivity prior to anesthetic instillation.
Key clinical pearls emphasized that disproportionate symptoms should prompt evaluation for NK, all corneal ulcers should be presumed infectious until proven otherwise, and PUK and NK can coexist and worsen corneal damage. Multimodal therapy and early consideration of regenerative treatments were highlighted as critical strategies to stabilize corneal melt and prevent progression.
Reference
Eslinger A, et al. Disproportionate Symptoms in Severe Corneal Thinning. Poster presented at: SECO2026; February 25–March 1, 2026; Atlanta, GA.
