Neurotrophic Keratitis Secondary To Radiotherapy Complicated With Descemetocele And Corneal Perforation. Management And Follow Up.

Descemtatocele is the protrusion of Descemet membrane and endothelium after thinning and melting of the entire corneal stroma. Neurotrophic keratitis is a well-known cause of corneal thinning. Management of these patients is challenging due to the high risk of perforation. The purpose of this report is to show a case of neurotrophic keratitis secondary to radiation therapy complicated by descemetocele and corneal perforation. We present management of the case through corneal gluing and follow-up with anterior segment OCT.

Clinical case with follow-up and management since July 2023 in the Ophthalmology Department  in a third level hospital in Jaén, Spain.

A case of a 67-year-old woman with personal history of nasopharyngeal carcinoma treated by chemotherapy and radiotherapy is exposed. Ophthalmic records include corneal leukoma in her OD since childhood with light perception. The patient presented at the clinic with redness on her right eye and pain, slit lamp revealed a central neurotrophic keratitis with deep stromal neovascularization.  Treatment with homologous serum 20% combined with insulin 1 U.I eye drops four times per day and oral valacyclovir twice was prescribed. Despite the epithelial defect healed properly, two months later recurrence with associated corneal thinning and central descemetocele occurred. The latter was microperforated regardless of intensive medical therapy.

The treatment for perforated descemetocele consisted of: corneal gluing with cyanoacrylate and sterile plastic piece along with bandage contact lens. After one month, the depth of the anterior chamber has been increased and the perforation has been sealed as can be seen in the images of anterior segment OCT. In the healing process the corneal stroma was remodelled with partial fibrosis over the descemetocele. The patient is currently pain-free with an anterior chamber formed and stable.

Radiotherapy used as treatment of head and neck cancer should be taken into account as a potential cause of neurotrophic keratitis. This could be produced by a dual mechanism: direct damage to the corneal nerves and affectation of trigeminal nerve which could lead to corneal denervation. In addition, the management of descemetocele is a challenge as the risk of perforation cannot be predicted. When it is perforated there are several therapeutic approaches which includes direct suturing, gluing for perforation <3 mm, amniotic membrane transplant, conjunctival flaps or therapeutic PK. In our case we opted for gluing since the dimensions of perforation were less than 3 mm with satisfactory result: quiet and well formed anterior chamber.