CaseWise 5 – Management of Corneal thinning

Dr. Prabhat Nangia, Dr. Sarang Lambat, Dr. Neha Shah, Dr. Vinay Nangia
Suraj Eye Institute, Nagpur, India

 Introduction

 Corneal perforation is a full thickness defect in the corneal stroma and can lead to profound vision loss, endophthalmitis and secondary glaucoma.1 In eyes with epithelial breakdown, bacteria may gain direct access to corneal stroma. This may cause increased recruitment of polymorphonuclear cells and pro inflammatory cytokines, causing increased stromal necrosis.1 Stromal thinning or perforation usually requires a tectonic intervention, including use of cyanoacrylate tissue adhesive2, multilayered amniotic membrane graft3, a conjunctival flap or a corneal patch graft.1

Case Report

A male, 70 years of age, came to us with chief complaints of pain with sudden diminution of vision in his right eye since 12 days following an injury with a stick and no significant systemic history. He had consulted elsewhere and was using topical natamycin 5% and topical moxifloxacin 0.5% eye drops 4 times a day each along with topical cycloplegics twice a day since 10 days with no improvement. On examination best corrected visual acuity (BCVA) was CF 2 metres in right eye and 6/9, N8 in left eye. Slit lamp examination showed a 3 by 3 mm epithelial defect in inferotemporal paracentral cornea with central 1.5 by 1.5 mm infiltrate (Fig 1A). Slit section examination showed variable thinning of the cornea in that area, with central thinning of about 80% (Fig 1B). An organised 1.5 mm hypopyon was present. Cornea in left eye was normal, and both eyes had immature cataract. Intraocular pressure in right eye was digitally normal, and left eye was 18 mmHg. Fundus examination was within normal limits. A provisional diagnosis of active infectious was made and corneal scraping was planned for microbiological diagnosis. During corneal scraping, absence of any active infiltrate was noted, with only debris present which was removed hence microbiological testing was deferred.

Figure 1 – Right eye showing 3 by 3 mm epithelial defect with debris and severe thinning (white arrow) in diffuse (A) and slit section image (B) along with an organised hypopyon (black arrow)

Management

The final diagnosis was post infectious corneal thinning. In view of significant tissue loss, an immediate tectonic procedure was necessary to prevent corneal perforation, and application of cyanoacrylate glue with bandage contact lens (BCL) was done with continuation of topical moxifloxacin drops 6 times a day. Patient was doing well post operatively and was symptomatically much better with significant reduction in hypopyon 5 days later (Fig 2 A). Three weeks after the glue with BCL was performed the eye continued to remain quiet (Fig 2 B) and patient was asked to review after 1 month. Since the eye was quiet, patient was asked to review again after one month, at this visit BCL was removed and wound was healed with no active infection (Fig 3).

Figure 2 – Right eye showing cyanoacrylate glue in situ (white arrow) with trace residual hypopyon (black arrow) 5 days after glue with BCL application; after 3 weeks (Fig 2B) hypopyon has disappeared completely (black arrow)

Figure 3 – Right eye showing 3 by 3 mm scar in the area of thinning (white arrow, Fig 3 A) without any epithelial defect (white arrow, Fig 3B)

Discussion

Cyanoacrylate glue is a non biological tissue adhesive that can arrest the process of stromal melting by preventing access of tear borne inflammatory cells to stromal tissue.4 It is also known to be bacteriostatic against gram positive bacteria, in addition to providing tectonic support. After application, the glue polymerises and forms a hardened seal over the perforation.5 We believe that our patient had developed infectious keratitis following a stick injury, that was adequately treated before he came to us, however the epithelial defect did not heal resulting in progressive thinning. Use of cyanoacrylate glue halts this process, removes residual infection if any, and also induces vascularisation and scarring. The glue helped prevent progression to corneal perforation and facilitated restoration of tectonic stability without any other procedures.

References

1. Jhanji V, Young AL, Mehta JS, Sharma N, Agarwal T, Vajpayee RB. Management of corneal perforation. Surv Ophthalmol. 2011;56(6):522‐538. DOI: 10.1016/j.survophthal.2011.06.003

2. Yin J, Singh RB, Al Karmi R, Yung A, Yu M, Dana R. Outcomes of Cyanoacrylate Tissue Adhesive Application in Corneal Thinning and Perforation. Cornea. 2019 Jun;38(6):668-673 DOI: 10.1097/ICO.0000000000001919

3. Solomon A, Meller D, Prabhasawat P, et al. Amniotic membrane grafts for nontraumatic corneal perforations, descemetoceles, and deep ulcers. Ophthalmology. 2002;109(4):694‐703 DOI: 10.1016/s0161-6420(01)01032-6

4. Lekskul M, Fracht HU, Cohen EJ, Rapuano CJ, Laibson PR. Nontraumatic corneal perforation. Cornea. 2000;19(3):313‐319.  

DOI: 10.1097/00003226-200005000-00011

5. Deshmukh R, Stevenson LJ, Vajpayee R. Management of corneal perforations: An update. Indian J Ophthalmol. 2020 Jan;68(1):7-14 DOI: 10.4103/ijo.IJO_1151_19

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