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Corneal perforation of torpid evolution as a presentation of severe bilateral neurotrophic keratopathy
First Author: N. Monja Alarcón SPAIN
Co Author(s): E. Corredera Salinero N. Alejandre Alba J. San Román Llorens M. Gabarrón Hermosilla P. Puy Gallego M. Buenasmañanas Maeso
To present a case of severe bilateral neurotrophic keratopathy (NK) that was presented clinically with a unilateral self-sealing perforation and vision loss. The evolution was torpid, requiring multiple immunosuppressive and anti-inflammatory drugs and several transplants to manage corneal melting.
Cornea and Ocular Surface Unit of Cornea, Ophthalmology Department, Fuenlabrada University Hospital and Fundaci�n Jim�nez D�az University Hospital, Madrid (Spain).
A 49-year-old woman poorly controlled diabetic, was referred with loss vision and mild discomfort without major pain in left eye (OS) after a coughing episode one week before. Slit-lamp examination revealed a sterile ulcer with stromal thinning (descemetocele) with a small self-sealing perforation in OS and a sterile non-perforated corneal ulcer in the right eye (OD). BCVA was 20/32 in OD and counting fingers at 1 meter in OS. The anterior chamber of the OS was significantly shallow. Corneal sensitivity was found to be reduced in both eyes. Intraocular pressure showed hypotonia on the OS.
It was managed with an amniotic membrane transplantation(AMT) in OS in addition to topical steroids, cyclosporine, antibiotics, autologous serum and oral levofloxacin. After one week, corneal melting was detected. Thus, tectonic penetrating keratoplasty was performed and oral doxycycline was started. One month later, a two-layer AMT with cyanoacrylate was decided after the observation of graft necrosis. A corneal melting occurred afresh, this time with progressive corneal thinning. Accordingly, the patient was referred to a transplant reference center where anterior lamellar keratoplasty(SALK) was performed. After one month, she presented an epithelial defect on the transplant, requiring a third AMT.
Systemic workup and laboratory tests were normal. For this reason, perforation and stromal melting could be explained by poorly controlled diabetes. This case illustrates the difficulties associated with the management of severe cases of NK, in which conventional treatment often results in failure and multiple surgical treatments are required. We consider that topical application of matrix regeneration therapy (RGTA) could have been beneficial in the management of this case, characterized by a torpid evolution and intense corneal melting even after TMA and keratoplasty. Unfortunately, these agents are no longer marketed in our country.
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