Impact Of Lagopthalmos: A Complicated Neurotrophic Ulcer. Regarding A Case.

To report and describe a clinical case of a complicated and treatment-resistant neurotrophic ulcer, despite receiving maximum medical therapy, in a poorly cooperative patient.

Clinical case.

A 77-year-old man with a history of lagophthalmos due to left peripheral facial paralysis from an acoustic neuroma presented with pain and redness in his left eye. On examination, he had a central corneal abscess and corneal melting, with positive fluorescein staining. The Tyndall effect is not appreciable, and the anterior chamber is well-formed. The diagnosis of infectious keratitis over a neurotrophic ulcer was suspected, and initial treatment included intensive antibiotics, cycloplegic drops, and intensive lubrication.  Microbiological cultures were taken, but they came back negative, and the condition did not improve after one week.

A lamellar keratectomy, temporal tarsorrhaphy, amniotic membrane transplant and new microbiological samples are taken were performed. Herpes simplex virus PCR came back positive, leading to the initiation of antiviral treatment and discontinuation of antibiotics. Despite additional amniotic membrane transplants and definitive tarsorrhaphy, the neurotrophic ulcer persisted for two months despite maximum medical treatment, including insulin eye drops and autologous serum.

At the last follow-up, the ulcer had closed, and the patient was suspected of good therapeutic compliance. However, botulinum toxin injection for ptosis was offered as further treatment.

A clinical case of a highly resistant ulcer is described, with treatment proving particularly challenging. Neurotrophic ulcers can be highly resistant, requiring a comprehensive and personalized approach for management. It is crucial to ensure the effective closure of the epithelial defect, utilizing reepithelialization maneuvers to prevent complications such as superinfection and perforation. In cases of infiltrated ulcers where there is diagnostic uncertainty, treatment should be approached as an infectious keratitis to avoid delays in intervention. Finally, it is essential to adopt a comprehensive approach that focuses not only on the ocular pathology but also considers the overall well-being of the patient.