TOPICAL NSAID INDUCED CORNEAL MELT: A CASE REPORT

To report a case of corneal melt secondary to post-operative topical non-steroidal anti-inflammatory drugs(NSAID) and highlight the importance of identifying patients at risk.

Royal Victoria Eye and Ear Hospital, Dublin, Ireland

A 77 year old female underwent uncomplicated left phacoemulsification and intraocular lens insertion on 22/09/2021. She was commenced on topical Maxitrol (dexamethasone, polymyxin B sulphate, neomycin sulphate) and Acular (Ketorolac) QDS post-operatively. She presented one week following with blurred vision and pain in her left eye and was noted to have a small corneal abrasion inferior to the visual axis. Vidisic 0.2% gel was added to her prescription. One week later, the epithelial defect had increased in size and anterior stromal deposits were noted. Chloramphenicol ointment was commenced and she was reviewed two days later, with no clinical improvement. Her condition did not improve over the following two weeks despite regular lubricants, topical antibiotics, topical steroids and bandage contact lens(BCL) placement and she was referred for a corneal specialist opinion.

On examination, her vision was 6/9 OD, CF OS, pinholing to 6/18. She was noted to have a large central corneal scar, severely dry ocular surface and central corneal thinning. The epithelial defect had resolved. Punctal cautery was performed bilaterally, the BCL was replaced and hourly Celluvisc  1% and BD Chloramphenicol minims were advised. She was reviewed regularly over the following 2-3 months with improvement in corneal wetting but persistent central stromal scar. Topical Fluorometholone(FML) BD was commenced and her vision improved to 6/24, pinhole 6/12. There was a large degree of anisometropia with an autorefraction of +1.25-0.75 x 83 on the right, and +8.00/-8.00 x 90 on the left.Options were discussed including contact lens placement and deep anterior lamellar keratoplasy, however the patient decline intervention.

This case highlights the importance of awareness of the major side effect of topical NSAIDs. It is essential to identify patient cohorts at risk pre-operatively to avoid adverse outcomes, particularly those with pre-existing ocular surface disease.