Oct-Guided Multilayer Amniotic Membrane For Occult Post-Herpetic Microperforation: Tectonic Stabilization And Avoidance Of Emergency Keratoplasty

To describe the management of a post-herpetic corneal microperforation in an eye with poor visual potential and high inflammatory risk, emphasizing a conservative tectonic approach focused on globe preservation rather than visual rehabilitation, and to highlight the need for ongoing optical coherence tomography (OCT)-guided surveillance given the risk of late recurrence.

Management and follow-up were performed at the Ophthalmology Department of Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal (November 2019 - February 2026).

A young woman with a longstanding post-herpetic central corneal scar (first documented in 2019) presented in 2025 with acute herpetic keratitis and severe stromal thinning. The eye had deep amblyopia (baseline visual acuity 1/10). The patient had Sjögren syndrome under immunomodulatory therapy. She was scheduled for corneal neovascularization cauterization and intrastromal bevacizumab; however, although no corneal perforation was present at clinical evaluation two days before surgery, on the day of surgery, prior to entering the operating room, a self-sealed microperforation with an iris plug was identified, leading to an immediate change in the surgical plan.

A multilayer amniotic membrane technique was used, consisting of one stromal plug, one double-faced layer placed epithelial side out, and an additional single overlay layer, secured with fibrin glue and limbal nylon sutures, with a therapeutic contact lens and systemic antivirals. Anterior segment OCT guided follow-up: the anterior chamber remained formed, inflammation was controlled, and OCT documented stromal thickening and epithelial healing; no keratoplasty was required and globe integrity was preserved. Two months later, recurrence occurred with epithelial defects, lipid keratopathy, and renewed superficial stromal loss with localized thinning on OCT; she was treated medically and with intrastromal bevacizumab.

In post-herpetic corneal melting, management may need to shift rapidly from anti-neovascular strategies to tectonic stabilization when an occult microperforation is detected. Multilayer amniotic membrane (plug + overlay) with a therapeutic contact lens, systemic antivirals, and anterior segment OCT monitoring provided effective support with progressive corneal thickening, and successfully avoided emergency keratoplasty. Late recurrence with renewed thinning can occur; continued OCT-guided monitoring and flexible anti-inflammatory and anti-neovascular escalation may preserve globe integrity in high-risk eyes.