‘A Crack In The Cornea’: Bilateral Tectonic Penetrating Keratoplasty In A Patient With Gonococcal Keratitis And Cocaine-Related Corneal Disease

Neisseria gonorrhoea is a highly virulent organism that can rapidly progress to perforation if prompt identification and treatment are not undertaken. ‘Crack eye syndrome’ (CES), commonly bilateral, can range from mild punctate keratitis through to perforation. We report a case of corneal perforation managed with tectonic penetrating keratoplasty (TPK) in a patient who was a frequent inhaled cocaine user, who tested positive for ocular gonorrhoea. We discuss the important considerations in management of such cases.

Peterborough City Hospital Foundation Trust, England, UK.

A 41-year-old female presented to our district general hospital with a two-week history of bilateral red eyes, purulent discharge and intense ocular pruritus resulting in vigorous eye rubbing. She wore daily disposable contact lenses and reported extensive inhaled recreational cocaine and heroin use. Bilateral visual acuity was perception of light. Examination revealed severely injected conjunctiva with papillae, right complete epithelial defect, thinning and abnormal corneal contour and left superior and inferior descemetocele. Conjunctival swabs taken were positive for gram-negative intracellular diplococci (Neisseria gonorrhoea). Despite initial promise to intensive topical therapy, the corneoscleral melt deteriorated significantly resulting in right corneal perforation, thus right TPK with a 12.5mm donor trephine was performed. Extensive corneoscleral melt was noted and during recipient trephination, despite viscoelastic formation of the anterior chamber, there was spontaneous iris and lens expulsion. One week later, left eye TPK was performed for worsening corneoscleral melt prior to perforation.

This is the first case report of ‘CES’ coexisting with ocular gonorrhoea. Over 10% of patients with ‘CES’ in one meta-analysis developed corneal perforation (2/18); whilst 31% (5/16) of patients with gonococcal keratitis progressed to perforation in another study. Better outcomes are reported for grafts performed after control of infection, however poor response to medical treatment and/or perforation may necessitate intervention. More extensive disease with scleral extension requires a larger graft, however there is an increased risk of secondary glaucoma, graft failure and poor visual outcomes. This case underlines the importance of considering these as a differential in severe keratitis, as well as initiating prompt intensive management.