Corneal Perforation In A Compromised Ocular Surface: The Hidden Danger Of Routine Postoperative Anti-Inflammatory Therapy In Primary Open Angle Glaucoma Patient

To present a case of spontaneous corneal perforation after uncomplicated cataract surgery in a glaucoma patient with ocular surface disease (OSD), underscoring the particular vulnerability of this population and the potential additive toxicity of standard postoperative NSAID and steroid therapy on a chronically compromised ocular surface.

Department of Ophthalmology, University Hospital Centre Zagreb, Croatia

A 79-year-old woman with long-standing primary open-angle glaucoma and significant OSD underwent uneventful phacoemulsification with IOL implantation. Due to intolerance to preserved drops, she was treated with preservative-free antiglaucoma therapy. However, chronic glaucoma treatment itself had already resulted in substantial surface damage.

Postoperative care included bromfenac and a combined antibiotic–steroid preparation, which are both administered routinely in postoperative care, but also known to further destabilize the tear film, especially after cataract surgery.

Five days after discontinuation of therapy, she presented with severe pain and decreased vision. Slit-lamp examination revealed a spontaneous corneal perforation with edema, shallow anterior chamber and anterior IOL displacement. No trauma was reported. Toxic corneal melt on a compromised surface was suspected.

Amniotic membrane transplantation initially restored anterior chamber depth. Subsequently, progressive anterior chamber flattening occurred due to aqueous misdirection, causing  elevated intraocular pressure (IOP) refractory to maximal medical therapy. Therefore, a pars plana anterior vitrectomy with hyaloido-zonulectomy and peripheral iridectomy was performed, resulting in re-formation of the anterior chamber and IOP stabilization. At discharge, the eye was pain-free with residual paracentral thinning and scarring.

Glaucoma patients represent a high-risk group due to chronic ocular surface damage, even when treated with preservative-free therapy. Those with coexisting OSD require an individualized postoperative approach, as standard NSAID therapy may trigger severe, sight-threatening complications such as corneal melt and perforation. Secondary aqueous misdirection may further complicate the course and require surgical management. Careful preoperative assessment of the ocular surface is essential for safe tailoring of postoperative treatment after cataract surgery.