Corneal Perforation After Uneventful Phacoemulsification Cataract Surgery In Rheumatoid Arthritis

To report a case of post-operative corneal melting in a patient with rheumatoid arthritis which can have serious ocular consequences. 

UAMS Health - Harvey & Bernice Jones Eye Institute Clinic

Seventy-four-year-old male presented to our emergency department with painless blurred vision in his left eye 1 week after uncomplicated cataract surgery. He had longstanding history of rheumatoid arthritis and was taking oral prednisolone 10 mg. His visual acuity was hand movement vision. Slit-lamp examination showed a melt at area of the side port and a second melt 2x2mm paracentral inferonasally, a positive Seidel test and flat anterior chamber. Mode B ultrasound showed no signs of endophthalmitis. 

Corneal perforation was glued with cyanoacrylate glue. The patient was put on prednisolone fortified eye drops, lubricants, antibiotic therapy, and a therapeutic bandage contact lens. Considering corneal melting due to systemic disease oral corticosteroid in higher dose (80mg daily) and close follow ups were initiated. At 8 weeks, corneal glue was holding well, corneal thinning and inflammation have settled, under 40 mg oral prednisolone. After 12 weeks, the patient was lost in follow ups. Four months after the procedure, he presented to the emergency department with a peripheral corneal perforation and dislocated IOL. A therapeutic keratoplasty combined with IOL removal and anterior vitrectomy was performed. Topical antibiotics with preservative-free tears and prednisolone fortified eye drops were started. Four weeks later, the ophthalmological examination found a visual acuity of 20/400. Slit lamp biomicroscopy revealed clear corneal graft. 

This is a case of an active rheumatoid arthritis complicated by corneal perforation in the left eye after cataract surgery. Sterile keratolysis after cataract extraction is a rare but serious complication. Therefore, meticulous preoperative assessment for both ocular and systemic risk factors is essential in this situation. Optimization of ocular surface prior to the surgery, dose adjustment of systemic treatment for rheumatoid arthritis, and close post-operative follow-ups can avoid such a serious complication.