Nsaid-Induced Corneal Melt As The First Presentation Of Sjögren’S Syndrome Following An Uncomplicated Cataract Surgery

We present a case of a patient with undiagnosed Sjögren's syndrome who experienced corneal perforation after receiving nonsteroidal anti-inflammatory drug (NSAID) prophylaxis for the prevention of cystoid macular oedema (CMO) following an uncomplicated cataract surgery. This case presentation highlights the importance of recognising the potential risks associated with NSAID use, including NSAID-induced corneal melt (NICM), particularly in patients with underlying autoimmune conditions such as Sjögren's syndrome. Furthermore, early patient presentation plays a pivotal role in achieving favorable outcomes, and as such, emphasizing patient education and empowerment, coupled with effective safety netting measures, is imperative.

A female patient in her late 80s presented to the emergency eye clinic one week post uneventful left eye cataract surgery, complaining of decreased visual acuity, gritty sensation, and photophobia in the same eye. The patient reported experiencing these symptoms since the second day after the surgery, which progressively worsened. On examination, the left eye exhibited a large corneal epithelial defect measuring 5x4 mm associated with underlying corneal thinning.

A non-diabetic female patient in her 80s presented one week following uncomplicated left eye cataract surgery complaining of decreased vision, gritty sensation, and photophobia in the same eye. Post-operative treatment included G. Acular (Ketorolac Tromethamine 0.5%, NSAID: non-steroidal anti-inflammatory drug) and G. Tobradex (Tobramycin 0.3% and Dexamethasone 0.1%, antibiotic and steroid respectively) each prescribed four times a day for two weeks. On examination, the patient had a corneal epithelial defect which progressed to a full-thickness perforation despite ceasing the NSAID drops. Cyanoacrylate glue application with a plastic drape patch failed to seal the perforation, and a full-thickness tectonic corneal transplant was performed. On investigation, the patient had positive autoimmune antibodies, including anti-RO and anti-LA antibodies, suggesting a diagnosis of Sjögren’s syndrome. Patient was commenced on topical cyclosporine 0.1% eye drops and advised to continue the course of medications prescribed following the corneal transplantion. On follow up, systemic immunosuppression was deferred in view of the patient’s overall health, localized nature of the disease to the patient’s eyes and that the ocular condition was stable on topical treatment.  

1. Along with close follow up, patient education plays a crucial role in ensuring early recognition of complications.
2. Sjögren's syndrome is often underdiagnosed and undertreated. Sjögren's syndrome should be suspected and investigations including Sjögren's auto-antibodies should be requested in patients presenting with corneal melt following routine cataract surgery. 
3. Prior to cataract surgery, careful pre-assessment is necessary to diagnose and treat underlying ophthalmic diseases, particularly conditions causing dry eyes.
4. The prescription of preservative-free eye drops is recommended, and topical NSAIDs should be prescribed judiciously or even avoided in patients with compromised ocular surfaces, considering the risk of corneal melt.