Three Cases of Corneal Melting After Instillation of a New Nonsteroidal Anti-Inflammatory Drug

Acanthamoeba keratitis with perforation after corneal crosslinking and bandage contact lens use

A 32-year-old man with keratoconus developed corneal melting 5 days after riboflavin/ultraviolet-A corneal collagen crosslinking (CXL). Corneal scraping was positive for Acanthamoeba. The patient was unaware that he was wearing a bandage contact lens and repeatedly rinsed his face and eyelids with tap water. Because of corneal perforation, a large therapeutic keratoplasty à chaud was performed. Although CXL is considered a safe procedure, this case emphasizes the potential risks. We discuss the potential effects of deepithelialization, contact lens placement, instillation of topical nonsteroidal antiinflammatory drugs and anesthetic agents, and the possible role of apoptosis when performing CXL treatment for keratoconus.

Management of ocular inflammation and pain following cataract surgery: focus on bromfenac ophthalmic solution

Recently, several new ophthalmic NSAID products have been introduced for commercial use in the United States. The purpose of this review is to briefly overview the ophthalmic NSAIDs currently in use and to discuss the management of postoperative ocular inflammation and pain following cataract surgery with a particular focus on bromfenac ophthalmic solution 0.09%. Bromfenac ophthalmic solution 0.09% is indicated for the reduction of ocular pain and inflammation following cataract surgery. Studies have shown that bromfenac ophthalmic solution 0.09% has equivalent efficacy to the other topical NSAIDs in reducing postsurgical inflammation and controlling pain. The unique chemical structure of bromfenac makes it both a potent inhibitor of the COX-2 enzyme and a highly lipophilic molecule that rapidly penetrates to produce early and sustained drug levels in all ocular tissues. Clinically, these pharmacokinetic features are manifested in a rapid reduction of postsurgical inflammation and pain with bid dosing. Bromfenac ophthalmic solution 0.09% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.

Corneal melt in lattice corneal dystrophy type II after cataract surgery

We report a patient with lattice corneal dystrophy type II, also known as Meretoja syndrome or familial amyloidosis Finnish type, who developed a corneal melt 15 days after uneventful phacoemulsification. Despite conservative treatment, the corneal melt resulted in perforation. Uneventful penetrating keratoplasty was performed, but delayed graft epithelial healing was noticed postoperatively. Corneal button histopathological evaluation confirmed the initial clinical diagnosis. To our knowledge, this is the first reported case of corneal melt and perforation in a patient with lattice corneal dystrophy type II.

Corneal melting and perforation in Stevens Johnson syndrome following topical bromfenac use

We report a case of a 20-year-old woman with tear deficiency secondary to Stevens Johnson syndrome who developed bilateral corneal melting following use of bromfenac (Xibrom), a nonsteroidal antiinflammatory drug (NSAID), for 2 weeks. The patient presented with complaints of light sensitivity and pain in the right eye. The slitlamp examination revealed a corneal perforation with iris plug in the right eye and an 85% thinned cornea in the left eye. She was admitted to the hospital, where Xibrom was discontinued, therapeutic contact lenses were placed, and a regimen of topical antibiotic agents was instituted. One day after admission, penetrating keratoplasty was performed in the right eye, an amniotic membrane was placed in the left eye, and tarsorrhaphy was performed bilaterally. The clinical features of this case highlight the importance of being selective when administering NSAIDs in patients with a compromised ocular surface.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.

Topical Bromfenac Sodium for Long-Term Management of Vernal Keratoconjunctivitis

BACKGROUND/AIMS

We evaluated the efficacy and safety of long-term management of patients with vernal keratoconjunctivitis (VKC) with bromfenac sodium eye drops in combination with corticosteroids and anti-allergic eye drops.

METHODS

Twenty-two patients with VKC were randomly assigned to receive two test eye drops, either bromfenac sodium 0.1% (group A) or placebo eye drops (normal saline; group B) for a mean observation period of 20.9 months. Topical corticosteroids and mast cell stabilizers were continued during the observation period.

RESULTS

The mean 2-year recurrence rate was 90.9% in group A and 11.3% in group B, with a significant difference. No serious side effect was observed in group A.

CONCLUSION

These results suggest that bromfenac sodium eye drops can be used as baseline local treatment in patients with VKC.

Demographic pattern, predisposing factors and management of ulcerative keratitis: evaluation of one thousand unilateral cases at a tertiary care centre

PURPOSE

To determine the predisposing factors, special clinical manifestations and the management of presumed microbial ulcerative keratitis.

METHODS

A retrospective study was performed in 1000 eyes of 1000 patients with presumed microbial keratitis. Information was recorded on patients' age and gender, risk factors, seasonal presentation, number of days since initiation of ulcer, prior therapy, clinical presentation, microbiological work-up and case management.

RESULTS

Fifty per cent of the patients with corneal ulcers were aged between 36 and 65 years and 13.3% were in the paediatric age group (1 month to <16 years). The male : female ratio was almost 1.6:1. Only 11.4% of patients reported to the authors during the first week of initiation of ulcer. Trauma was the cause in 47.6% of eyes, and ocular surface diseases accounted for 16.6%. Forty-two per cent of eyes received topical antibiotics alone (either one or more) prior to hospital visit and 42.2% of eyes were on topical antibiotics and antifungals. Another 8.2% were on topical corticosteroids along with antibiotics and 4.6% were receiving some unidentified drop. Only 3% of the eyes did not receive any therapy prior to visit. Contact lens use as a risk factor could be identified only in 8.2% of eyes. Ulcers were central in location in 48%. Ulcer size 6-9 mm was observed in 51.7% of eyes. Medical therapy alone was effective in 61.0% of eyes and another 9.7% eyes responded to paramedian tarsorrhaphy along with topical antimicroboial drugs.

CONCLUSION

Corneal ulcers are a frequent problem in this part of the world. The ulcers seen at this tertiary referral hospital present late in the natural history of the disease and are clinically severe. Despite the severity a majority of the eyes could be saved anatomically, but almost 65% of eyes were left with a visual acuity of <6/120. Considering the high magnitude of visual loss, public education about the potential for loss of sight and the importance of timely and appropriate treatment is recommended.

Science and Strategy for Preventing and Managing Corneal Ulceration

ABSTRACT Corneal ulcers can cause significant loss of vision from scarring and astigmatism, but rapid management can limit the destruction and improve outcomes. Infectious ulcers usually resolve with antimicrobial treatment. Noninfectious ulcers, however, present a diagnostic and therapeutic challenge. They can often be resolved by eliminating toxic medications and providing surface support with lubrication and collagenase inhibitors, but resistant ulcers may need more aggressive therapy with bandage contact lenses, tarsorrhaphy, or autologous serum. Ulcers impending perforation require urgent surgical management (e.g., tissue glue, conjunctival flaps, or keratoplasty). Topical steroids are useful when the ulceration is secondary to inflammatory mediators, but they are contraindicated in corneal melts with minimal inflammation, such as those associated with Sjogren syndrome. Systemic immunomodulation is required in addition to topical therapy in the presence of autoimmune disease. Understanding of the pathological processes that occur in different types of corneal ulcers is essential to formulation of a logical and effective treatment plan. Newer, more targeted treatment modalities may offer treatment options that have greater efficacy and fewer adverse effects.