Corneal Melting : The Tip Of The Iceberg Revealing Sjogren’S Syndrome

As clinicians, how often do we dismiss persistent dry eye as a minor issue, not realizing it could be an early indicator of a serious systemic autoimmune disease , his case  demonstrates the profound consequences of a delayed diagnosis . We received a 55-year-old woman with severe dry eye and recurrent corneal ulcers refractory to topical treatments. Her medical history revealed chronic joint pain , along with symptoms of oral and vaginal dryness. On examination, her visual acuity was limited to hand movements in the right eye and 1/20 in the left eye. She exhibited severe meibomian gland dysfunction . The right eye had deep, sterile corneal melting , while the left eye showed diffuse corneal erosions .

diagnostic tests confirmed severe aqueous tear deficiency, with a TBUT of less than 10 sec and a Schirmer’s test showing only 2 mm of wetting . interferometry demonstrated a markedly reduced lipid layer. Meibography  confirmed this by showing over 80% loss of meibomian glands,  the anterior segment OCT revealed .  significant stromal loss  espacialy in the right .

The diagnosis of primary Sjögren’s syndrome was  confirmed through biological tests  and a salivary gland biopsy

Given the critical risk of corneal perforation in the right eye, we initiated multilayered therapeutic amniotic membrane grafting and applied soft bandage contact lenses to promote stromal healing. Following this, both eyes were treated with topical immunosuppressants, including ciclosporine A and corticosteroids, as well as autologous serum eye drops and intensive preservative-free artificial tears. To further improve tear retention, punctal plugs were inserted. Once stability was achieved, we introduced Intense Pulsed Light (IPL) therapy combined with BlephEx to restore meibomian gland function and further stabilize the ocular surface. Additionally, the patient was referred to a rheumatologist for a specialized evaluation.

The patient’s recovery was marked by successful healing of corneal melting, though residual corneal opacities and neovascularization persisted. At the two-month follow-up, visual acuity improved to counting fingers at two meters in the right eye and 2/10 in the left. OCT revealed compensatory epithelial hyperplasia over the stromal defect, indicating clear stabilization. Scleral lenses are strongly recommended to improve visual acuity, as keratoplasty may be needed in the future but carries a high risk of failure.

In conclusion, this case highlights the critical need to address both aqueous-deficient and evaporative components in managing Sjögren’s syndrome dry eye. Understanding this dual approach is vital for optimizing both diagnosis and treatment.

The severe risk of corneal perforation in this case required an intensive, multifaceted strategy. Recent studies show that emerging therapies, including IPL, immunosuppressants, and biotherapy which targets specific inflammatory pathways, has gained recognition as a promising long-term solution for Sjögren’s dry eye, offering hope for patients with persistent or severe symptoms.