Download - Corneal Perforation After Topical Nepafenac Eyedrops In A Case Of Ocular Surface Disorder
Corneal Perforation after topical Nepafenac eyedrops
in a case of ocular surface disorder
Dr. Priya Srinivas FRCS, Cornea Fellow, Sankara Nethralaya
Shree Eye care, Mumbai
Case Report
Purpose
To report a case of corneal melt in a patient who was prescribed topical Nepafenac for irritation in her right eye
Topical Non Steroidal Anti Inflammatory Drugs (NSAIDs) are routinely used for inflammation after cataract surgery, for pain after PRK, to prevent intraoperative miosis in cataract surgery and ocular allergies
Although they are widely used without incident some patients are predisposed to serious complications
Methods
A 58 year old female was referred for diminution of vision, redness and swelling of her right eye over the past 15 days
She was prescribed Nepafenac eyedrops for irritation in her right eye thrice daily for 15 days before presentation
She had undergone cataract surgery 6 years ago in both eyes Her systemic condition was unremarkable except for vitiligo
patches
Clinical presentationEye Right eye (OD) Left eye(OS)BCVA Perception of light, PR accurate 6/9 N6
Lids Meibomian gland dysfunction (MGD) Meibomian gland dysfunction (MGD) Grade 3
Conjunctiva Circumciliary congestion Normal,quietCornea Infitrate (Catarrhal infiltrate), pannus,
microperforation, positive Seidel 's test Punctate epithelial erosions (PEEs)in inferior 1/3rd of cornea
Schirmers II Not assessed 18 mmTear Break Up Time Not assessed 3 secondsAnterior chamber Fibrinous exudates and hypopyon Normal depth and quietPupil Sluggish RTL Normal reacting to light
Lens Pseudophakia Pseudophakia
Intra Ocular Pressure Not assessed 12 mm Hg
Fundus No view Normal
Methods
MethodsShe was prescribed :antibiotic eyedropscycloplegic eyedropspreservative free lubricantsOral doxycycline 100 mg twice daily for 1 weekNepafenac eyedrops stoppedImmunology tests - ESR, CRP, RA factor, ANA, ANCA - negativeTissue adhesive (cyanoacrylate glue) with Bandage contact lens
1 day 2 weeks
Results
Quiet surface and well resolved scar
Yag Capsulotomy after 7 months
BCVA in the right eye
Distance Near
1 month 6/24 N12
7 months 6/12 P N8
Results
Discussion
NSAIDs are anti-inflammatory drugs that inhibit cyclo-oxygenase activity and decrease the synthesis of prostaglandins
They act by altering the cytoskeleton structure of epithelial cells, decreasing corneal sensitivity by altering the flow of ions at neuroreceptors thereby impairing corneal epithelial healing
They cause aberrant expression of matrix metalloproteinases in the cornea, leading to ulcerative keratolysis
Discussion
Literature abounds with reports of corneal melts associated with almost all formulations of NSAIDs (Diclofenac1, Bromfenac3 and Nepafenac2)
They have to be avoided in patients with an impaired ocular surface e.g. Diabetics with an impaired ocular surface, Rosacea, Neurotrophic corneas, previous chemical burns, Graft vs host disease, epithelial defects, dry eyes, Rheumatoid arthritis
1 Lin et al : Corneal Melting Associated With Use of Topical Nonsteroidal Anti-inflammatory Drugs After Ocular Surgery -Arch Ophthalmol 2000;118(8):1129-1132.
2 Peter D. Bekendam .Case of Corneal Melting Associated With the Use of Topical Nepafenac: Cornea 2007;26:1002–10033 Tatsuhiko Asai et al. Three cases of corneal melting after instillation of a new nonsteroidal anti-inflammatory drug.Cornea 2006
Feb;25(2):224-7
Discussion In our case, an assessment of the ocular surface to ascertain the cause of
irritation at the initial presentation was needed The nature of the infiltrate, the meibomian gland dysfunction and tell tale
signs of the other eye pointed to a catarrhal etiology An already compromised ocular surface, lack of close monitoring and topical
NSAIDs (Nepafenac) All contributed to the corneal epithelial breakdown resulting in a corneal melt and perforation
Examination of the ocular surface and timely institution of tectonic procedure with a tissue adhesive helped in restoring the ocular surface and thereby improved the visual acuity
Conclusion
Topical NSAIDs have a great role in reducing inflammation in certain indications
But they need to be administered with caution in patients with ocular surface disease
A close follow up and minimal dosing is warranted The prescribing clinician has to keep in mind the possible
catastrophic events including melting and perforation.