Dr. Priya Srinivas Frcs,Cornea Fellow,Sankara Nethralaya Shree Eye Care, Mumbai

1. 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

2. 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

3. 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

4. Clinical presentation
Eye 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,quiet
Cornea Infitrate (Catarrhal infiltrate), pannus,
microperforation, positive Seidel 's test
Punctate epithelial erosions (PEEs)
in inferior 1/3rd of cornea
Schirmers II Not assessed 18 mm
Tear Break Up Time Not assessed 3 seconds
Anterior chamber Fibrinous exudates and hypopyon Normal depth and quiet
Pupil Sluggish RTL Normal reacting to light
Lens Pseudophakia Pseudophakia
Intra Ocular Pressure Not assessed 12 mm Hg
Fundus No view Normal

5. Methods

6. Methods
She was prescribed :

antibiotic eyedrops

cycloplegic eyedrops

preservative free lubricants

Oral doxycycline 100 mg twice daily for 1 week

Nepafenac eyedrops stopped

Immunology tests - ESR, CRP, RA factor, ANA, ANCA - negative

Tissue adhesive (cyanoacrylate glue) with Bandage contact lens

7. 1 day 2 weeks
Results

8. 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

9. 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

10. Discussion

Literature abounds with reports of corneal melts associated with
almost all formulations of NSAIDs
(Diclofenac
1
, Bromfenac
3
and Nepafenac
2
)

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;26:1002–1003
3 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

11. 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

12. 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.