Peripheral Corneal Thinning

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  • Peripheral corneal thinning ± sterile infiltrate or ulcer

Differential Diagnoses

  • Peripheral Ulcerative Keratitis (PUK)
    • Group of inflammatory diseases leading to peripheral corneal thinning
    • Unilateral or bilateral
    • Crescent-shaped ulceration and stromal infiltration at the limbus, epithelial defect. Circular and occasionally central spread 1 2 3 4
    • Mostly limbitis, episcleritis, scleritis. Perforation can occur.
    • Often associated with dry eye
    • Systemic comorbidities must be investigated!
      • Rheumatoid arthritis (most common)
      • Granulomatosis with Polyangiitis (second most common)
      • Relapsing Polychondritis
      • Systemic lupus erythematosus
  • Mooren’s Ulcer
    • Special form of PUK without scleritis, by definition idiopathic without local or systemic underlying disease, diagnosis by exclusion!
    • Unilateral or bilateral
    • Severe pain is typical
    • Peripheral stromal ulcerations with epithelial defect, central lesion with overhanging edge, usually starting nasally or temporally with circular and later central spread; infiltrations at the periphery, vascularisations.
  • Terrien’s Marginal Degeneration
    • Mostly bilateral
    • Often asymptomatic
    • No epithelial defect
    • Slowly progressive thinning of the peripheral cornea, typically superior; sometimes with yellowish linear deposition (lipids), irregular astigmatism possible 5 6
  • Corneal Dellen
    • Localized, mostly oval corneal thinning; usually next to a raised lesion
    • Caused by drying -> lubricating drops
  • Pellucid Marginal Degeneration
  • Marginal keratitis
  • Ocular Rosacea
  • Senile Furrow Degeneration
    • decreasing width of the peripheral cornea between the arcus senilis and limbus


  • History: especially systemic (rheumatic) or ocular pre-existing conditions?
  • Complete slit-lamp examination including fundoscopy (Cotton-Wool spots? Signs of posterior scleritis?)
  • consider Schirmer test
  • Laboratory tests: Complete blood count, CRP, ESR, RF, anti citrullinated protein antibodies (ACPA), ANA, ANCA
  • corneal swab when infectious aetiology is suspected
  • consider scleritis – workup


  • Local (usually not sufficient!)
    • Intensive lubrication, punctum plugs, ciclosporin gtt or autologous serum eye drops
    • bandage contact lens
    • Floxal UD (Ofloxacin) 3-4x/d, topical steroids, e.g., Pred Forte gtt (prednisolone)
  • Systemic
    • Systemic high-dose corticosteroids/immunosuppression (interdisciplinary with rheumatologist)
    • consider oral tetracyclines, e.g., Doxycycline 100mg 2x/d (anti-collagenase activity)
  • Surgical
    • for small lesions, consider conjunctival resection at the limbus near the lesion
    • consider lamellar keratoplasty, amniotic membrane transplantation