Management Of Bilateral Corneal Perforation Secondary To Severe Exposure Keratopathy In A Neurologically Impaired Patient: Sequential Keratoplasty And Definitive Tarsorrhaphy

To report a case of bilateral corneal perforation secondary to severe exposure keratopathy in a neurologically impaired patient. Surgical management involved sequential bilateral keratoplasty and definitive tarsorrhaphy performed in a single surgical session. This case underscores the necessity of addressing the underlying exposure mechanism to ensure surgical success and prevent recurrence.

Hospital de Clínicas “José de San Martín”, University of Buenos Aires, Buenos Aires, Argentina.

A 25-year-old female with cerebral palsy and developmental delay was referred with bilateral corneal perforation secondary to refractory exposure keratopathy. Visual acuity assessment was not possible due to poor cooperation. Ophthalmologic examination revealed horizontal nystagmus, bilateral lagophthalmos, and absence of spontaneous blinking. Slit-lamp examination showed conjunctival hyperemia, mucous discharge, 360-degree corneal neovascularization, progressive corneal melting, and bilateral 2 × 2 mm paracentral corneal perforations associated with ocular hypotony (Figure 1).

Bilateral therapeutic penetrating keratoplasty combined with permanent tarsorrhaphy was performed during the same surgical session. Each eye was operated sequentially, with complete operating room re-sterilization between procedures, including surgical field re-preparation, replacement of the corneal transplantation instrument set, and change of the primary surgeon within the same surgical team to minimize the risk of cross-contamination (Figures 2 and 3).

In neurologically impaired patients, chronic exposure due to lagophthalmos and absent blinking may lead to progressive corneal melting and bilateral perforation. Effective management must address both the structural corneal damage and the underlying exposure mechanism. Sequential bilateral keratoplasty can be safely performed in a single surgical session under strict aseptic protocols, while definitive tarsorrhaphy is essential to eliminate the primary pathogenic factor and prevent recurrence.