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.