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Novel Use of HP Acther Gel in the Treatment of Peripheral Ulcerative Keratitis

John C Affeldt, MD

Presenter:

John C Affeldt, MD

Authors:

Affiliation:

Loma Linda University Eye Institute

  1. TITLE
  2. Novel Use of HP Acthar Gel in the Treatment of Peripheral Ulcerative Keratitis
  3. PURPOSE
  4. To document for the first time the use of HP Acthar Gel in the treatment of peripheral ulcerative keratitis
  5. METHODS
  6. Retrospective case report
  7. RESULTS
  8. On 7/16/19, a 56 yo Caucasian female presented with a 4 month history of increasing pain, redness and declining vision OD. BCVA was 20/60 OD and HM OS. Slit lamp exam (SLE) OD revealed 9 clock hours of peripheral stromal infiltrate with stain defect, and 1 clock hour of guttered 90% stromal melt centered at the 1:30 limbus (see Figure 1A). SLE OS revealed 4 clock hours of limbal ischemia with associated mild peripheral stromal thinning and stain defect, and a 4+ mature white cataract (see Figure 1B). The patient was diagnosed with severe peripheral ulcerative keratitis (PUK) and started on oral prednisone 60mg QD. Two weeks later with the disease progressing, the patient was hospitalized for emergent rheumatology intervention.
  9. She was diagnosed with severe relapsing polychondritis, administered methylprednisolone 1gm QD x3 days, initiated on the first of 6 intended monthly Cytoxan infusions, and continued oral prednisone 60mg QD. Problematic rheumatology follow up coupled with patient availability issues resulted in delay to the second Cytoxan infusion for 3 1/2 months. In the meantime, with continued disease progression, HP Acthar Gel was initiated as a rescue agent on 8/21/9 at 80u Q-3 days.
  10. Symptom improvement was first noted 2 weeks later; active keratitis (AK) regression documented OU 3 weeks later; continued AK regression OD and complete AK control OS noted 10/15/19; Acthar increased by rheumatology to 80u QOD on 10/22/19; the second Cytoxan infusion received 11/8/19; continued total AK control OS 11/13/19 with only focal residual AK OD (12:00), but limbal perforation with iris prolapse OD at the 1:30 thinning site; penetrating keratoplasty performed OD 12/3/19; the third Cytoxan infusion received 12/10/19; complete PUK control noted OU 12/12/19; the fourth and fifth Cytoxan infusions provided 1/9/20 and 2/7/20 respectively; and at last exam 2/14/20, a clear stable transplant OD, 4+ mature white cataracts OU, and complete PUK control OU while continuing oral prednisone taper and Acthar 80u QOD (see Figure 2).
  11. CONCLUSIONS
  12. HP Acther Gel may be considered as an alternative or additional immunosuppressive agent in the treatment of peripheral ulcerative keratitis

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