eMedicine Specialties > Ophthalmology > Cornea

Corneal Melt, Postoperative: Differential Diagnoses & Workup

Author: Arun Verma, MD, Senior Consultant, Department of Ophthalmology, Dr Daljit Singh Eye Hospital, India
Contributor Information and Disclosures

Updated: Jun 10, 2008

Differential Diagnoses

Central Sterile Corneal Ulceration
Corneal Edema, Postoperative
Herpes Simplex
Herpes Zoster
Sjogren Syndrome

Other Problems to Be Considered

Marginal dystrophy - Degenerative chronic corneal lesion and stromal thinning and intact epithelium occurs in individuals younger than 40 years
Marginal ulceration - Secondary to massive granuloma of sclera or necrotizing nodular scleritis
Mooren ulcer
Terrien marginal degeneration
Wegener granulomatosis

Workup

Laboratory Studies

  • Investigations  
    • Impression cytology to detect conjunctivalization for diagnosing stem cell deficiency. Identifying the underlying cause is as important as making the diagnosis of the perforation. In trauma, the history often is sufficient to make the diagnosis. In infections, laboratory confirmation is important, and scraping and culture are often essential.
    • At times, corneal biopsy may be necessary and may be part of the definitive treatment of the perforation, with the excised cornea at keratoplasty being used to make the diagnosis.
    • External ocular examination including evaluation of lid function and anatomy, testing of corneal sensation, and evaluation of tear function may help to establish the etiologic diagnosis.
    • In noninfectious inflammatory corneal melting, an evaluation for systemic inflammatory disease may be necessary.
  • Tests to rule out collagen vascular disease
    • The erythrocyte sedimentation rate may be elevated in cases of orbital inflammation, but this should bring to mind the possibility of a concurrent systemic disease such as one of the collagen vascular diseases.
    • Circulating immune complexes may deposit in the limbal vasculature, triggering complement activation, influx of inflammatory cells, and release of enzymes and mediators. The result is a limbal vasculitis; the subsequent loss of vascular integrity facilitates leakage of inflammatory cells and mediators into the peripheral cornea. Immune complexes may leak into the peripheral cornea as well, sparking complement activation, especially with the increased concentration of C1 in the peripheral cornea. Also, it is possible that autoantibodies to corneal epithelial and/or stromal antigen may arrive via the limbal vasculature or via the tear film and play a role. T cells and activated macrophages have been found in active rheumatoid arthritis associated corneal melts, suggesting cell-mediated mechanisms. Collagenase produced by the adjacent conjunctiva and keratocytes and polymorphonuclear leukocytes (PMNs) in the cornea promote stromal dissolution.
    • In a reported case of postoperative corneal melt, light microscopy revealed a thickened corneal epithelium with an irregular Bowman layer and mild infiltration of the superficial stroma with inflammatory cells, mostly lymphocytes but some PMNs. The adjacent conjunctiva also showed some infiltration by lymphocytes. Immunohistochemistry showed expression of class II antigens on less than 25% of corneal epithelial cells and keratocytes compared with 75-100% of cells in a Mooren ulcer specimen. Less than 5% of lymphocytes were B cells, versus 25-50% in the Mooren specimen. Also, T-cell numbers were much lower in the corneal melt cases; the ratio of helper T cells to suppressor/cytotoxic T cells was 1:1, compared with 2.4:1 for the Mooren sample.
    • Since all the collagen vascular diseases are basically immune complex diseases, there would be finding of circulating immune complexes. There is great variability from disease to disease in the frequency of positive immune-complex assays. In some diseases, such as systemic lupus erythematosus (SLE), there is a high frequency of positive immune-complex assays. In others, the frequency of positive assays may be much lower.
      • Examination of tissues using immunofluorescent techniques to detect immune deposits is also important in establishing the diagnosis of immune-complex disease. Immune complexes deposited in tissues may be evanescent. In fact, it has been suggested that the levels of serum C4 and C3 are the most sensitive indexes of disease activity of SLE.
      • Other tests may suggest indirectly the presence of immune-complex disease. For example, the finding of immunoglobulin M (IgM) cryoprecipitates suggests the presence of immune complexes. The presence of antinuclear antibodies suggests autoimmunity, as does the presence of a number of tissue-component–specific antibodies. Similarly, the presence of specific antigen such as hepatitis-B surface antigen in the circulation together with appropriate clinical symptoms may suggest an immune-complex disease. Many patients with these diseases have an elevated erythrocyte sedimentation rate.
    • In SLE, the presence of characteristic antibodies such as anti-DNA, anti-Sm, and anti-RNP confirms the diagnosis of SLE. Antinuclear antibodies are the best screening tests. High serum levels of antinuclear antibodies anti-DNA and low levels of complement usually reflect disease activity.
    • Serum levels of cryoglobulins or other immune complexes occasionally correlate with disease activity. Total functional hemolytic complement (CH50) levels are the most sensitive measure of complement activation. Quantitative levels of C3 and C4 are widely available. Hematologic abnormalities are common and include anemia (usually normochromic, normocytic but occasionally hemolytic), leucopenia, lymphopenia, and thrombocytopenia. In some patients, the Westergren erythrocyte sedimentation rate correlates with disease activity. Urinalysis and serum creatinine should be measured periodically in these patients.
    • In patients with rheumatoid arthritis, no tests are specific, but, rheumatoid factors, which are autoantibodies reactive with Fc portion of immunoglobulin G (IgG), are found in more than two thirds of the patients. Widely used tests detect IgM rheumatoid factors.
    • Rheumatoid factor is present in about 75% of patients with Sjögren syndrome even when symptoms of arthritis are absent. Antinuclear antibodies are present in about 70% of patients, and a positive lupus erythematosus (LE) cell test occurs in about 25% of patients. Two antinuclear antibodies, SS-A and SS-B, usually are associated with Sjögren syndrome. SS-B antibodies are found in up to 70% of patients and are fairly specific for the diagnosis of this disease. SS-A antibodies are found in up to 14% of patients. There is a high incidence of antibodies against Epstein-Barr virus nuclear antigen and human leukocyte antigen Dw3 (HLA-Dw3).
    • Collagen vascular diseases such as rheumatoid arthritis, polyarteritis nodosa, and Wegener granulomatosis can be associated with sterile peripheral corneal melting ulceration, either with or without adjacent scleritis. The pathophysiology of such ulceration undoubtedly is linked to the underlying autoimmune mechanisms of each of these diseases and is probably similar for all. This is supported clinically by the fact that those patients with rheumatoid arthritis who develop necrotizing scleritis or peripheral ulcerative keratitis have an increased mortality rate because of systemic vasculitis.

Histologic Findings

Loss of limbal stem cells and stromal cells

More on Corneal Melt, Postoperative

Overview: Corneal Melt, Postoperative
Differential Diagnoses & Workup: Corneal Melt, Postoperative
Treatment & Medication: Corneal Melt, Postoperative
Follow-up: Corneal Melt, Postoperative
References
[ CLOSE WINDOW ]

References

  1. Cottinger, AJ, Berkley, RP, Nordan IT, et al. Bacterial corneal ulcers following keratorefractive surgery. In: A retrospective study of 14163 procedures. Paper presented at: Ocular Microbiology Immunology Group Meeting. San Francisco, CA; September 28, 1985.

  2. Yang HK, Kline OR Jr. Corneal melting with intraocular lenses. Arch Ophthalmol. Aug 1982;100(8):1272-4. [Medline].

  3. Gelender H. Descemetocele after intraocular lens implantation. Arch Ophthalmol. Jan 1982;100(1):72-6. [Medline].

  4. Insler MS, Boutros G, Boulware DW. Corneal ulceration following cataract surgery in patients with rheumatoid arthritis. J Am Intraocul Implant Soc. Nov 1985;11(6):594-7. [Medline].

  5. Barletta JP, Angella G, Balch KC, Dimova HG, Stern GA, Moser MT, et al. Inhibition of pseudomonal ulceration in rabbit corneas by a synthetic matrix metalloproteinase inhibitor. Invest Ophthalmol Vis Sci. Jan 1996;37(1):20-8. [Medline].

  6. Barletta JP, Balch KC, Dimova, et al. Inhibition of Pseudomonas corneal ulcers by a synthetic matrix metalloprotease inhibitor Galardin (GM[6001]). Invest Ophthalmol Vis Sci. 1993;34:1058.

  7. Benson WE, Diamond JG, Tasman W. Intraocular irrigating solutions for pars plana vitrectomy. A prospective, randomized, double-blind study. Arch Ophthalmol. Jun 1981;99(6):1013-5. [Medline].

  8. Bernauer W, Ficker LA, Watson PG, Dart JK. The management of corneal perforations associated with rheumatoid arthritis. An analysis of 32 eyes. Ophthalmology. Sep 1995;102(9):1325-37. [Medline].

  9. Binder PS, Baumgartner SD, Fogle JA. Histopathology of a case of epikeratophakia (aphakic epikeratoplasty). Arch Ophthalmol. Sep 1985;103(9):1357-63. [Medline].

  10. Binder PS, Zavala EY. Why do some epikeratoplasties fail?. Arch Ophthalmol. Jan 1987;105(1):63-9. [Medline].

  11. Cameron ME. Preventable complications of pterygium excision with beta-irradiation. Br J Ophthalmol. Jan 1972;56(1):52-6. [Medline].

  12. Castillo A, Diaz-Valle D, Gutierrez AR, Toledano N, Romero F. Peripheral melt of flap after laser in situ keratomileusis. J Refract Surg. Jan-Feb 1998;14(1):61-3. [Medline].

  13. Chung H, Tolentino FI, Cajita VN, Acosta J, Refojo MF. Reevaluation of corneal complications after closed vitrectomy. Arch Ophthalmol. Jul 1988;106(7):916-9. [Medline].

  14. Clewes AR, Tunn EJ, Kaye S, Bucknall RC. Use of intravenous cyclophosphamide in the prevention of corneal melt: justified or not?. Rheumatology (Oxford). Feb 2005;44(2):257-8. [Medline].

  15. Dougherty PJ, Hardten DR, Lindstrom RL. Corneoscleral melt after pterygium surgery using a single intraoperative application of mitomycin-C. Cornea. Sep 1996;15(5):537-40. [Medline].

  16. Dua HS, Saini JS, Azuara-Blanco A, Gupta P. Limbal stem cell deficiency: concept, aetiology, clinical presentation, diagnosis and management. Indian J Ophthalmol. Jun 2000;48(2):83-92. [Medline].

  17. Edelhauser HF, Hine JE, Pederson H, Van Horn DL, Schultz RO. The effect of phenylephrine on the cornea. Arch Ophthalmol. May 1979;97(5):937-47. [Medline].

  18. Ewing-Chow DA, Romanchuk KG, Gilmour GR, Underhill JH, Climenhaga DB. Corneal melting after pterygium removal followed by topical mitomycin C therapy. Can J Ophthalmol. Jun 1992;27(4):197-9. [Medline].

  19. Farrell PL, Smith RE. Bacterial corneoscleritis complicating pterygium excision. Am J Ophthalmol. May 15 1989;107(5):515-7. [Medline].

  20. Foulks GN, Thoft RA, Perry HD, Tolentino FI. Factors related to corneal epithelial complications after closed vitrectomy in diabetics. Arch Ophthalmol. Jun 1979;97(6):1076-8. [Medline].

  21. Geerling G, Joussen AM, Daniels JT, Mulholland B, Khaw PT, Dart JK. Matrix metalloproteinases in sterile corneal melts. Ann N Y Acad Sci. Jun 30 1999;878:571-4. [Medline].

  22. Gelender H. Corneal melting syndrome. Arch Ophthalmol. Feb 1983;101(2):303. [Medline].

  23. Gilliland GD, Hutton WL, Fuller DG. Retained intravitreal lens fragments after cataract surgery. Ophthalmology. Aug 1992;99(8):1263-7; discussion 1268-9. [Medline].

  24. Grayson, M. Diseases of the Cornea. 2nd ed. St Louis: CV Mosby; 1983.

  25. Gupta S, Basti S. Corneoscleral, ciliary body, and vitreoretinal toxicity after excessive instillation of mitomycin C. Am J Ophthalmol. Oct 15 1992;114(4):503-4. [Medline].

  26. Hoffer KJ, Darin JJ, Pettit TH, Hofbauer JD, Elander R, Levenson JE. Three years experience with radial keratotomy. The UCLA study. Ophthalmology. Jun 1983;90(6):627-36. [Medline].

  27. Hong C, Kitazawa Y, Tanishima T. Influence of argon laser treatment of glaucoma on corneal endothelium. Jpn J Ophthalmol. 1983;27(4):567-74. [Medline].

  28. Lam DS, Leung AT, Wu JT, Fan DS, Cheng AC, Wang Z. Culture-negative ulcerative keratitis after laser in situ keratomileusis. J Cataract Refract Surg. Jul 1999;25(7):1004-8. [Medline].

  29. Latina MA, Melamed S, March WF, Kass MA, Kolker AE. Gonioscopic ab interno laser sclerostomy. A pilot study in glaucoma patients. Ophthalmology. Nov 1992;99(11):1736-44. [Medline].

  30. Leahey AB, Gottsch JD, Stark WJ. Clinical experience with N-butyl cyanoacrylate (Nexacryl) tissue adhesive. Ophthalmology. Feb 1993;100(2):173-80. [Medline].

  31. Lemp MA. Cornea and sclera. Arch Ophthalmol. Aug 1974;92(2):158-70. [Medline].

  32. Liu SM, Su J, Hemady RK. Corneal melting after avulsion of a Molteno shunt plate. J Glaucoma. Dec 1997;6(6):357-8. [Medline].

  33. Mamalis N, Johnson MD, Haines JM, Teske MP, Olson RJ. Corneal-scleral melt in association with cataract surgery and intraocular lenses: a report of four cases. J Cataract Refract Surg. Jan 1990;16(1):108-15. [Medline].

  34. Mandelbaum S, Waring GO 3rd, Forster RK, Culbertson WW, Rowsey JJ, Espinal ME. Late development of ulcerative keratitis in radial keratotomy scars. Arch Ophthalmol. Aug 1986;104(8):1156-60. [Medline].

  35. Margherio RR, Cox MS Jr, Trese MT, Murphy PL, Johnson J, Minor LA. Removal of epimacular membranes. Ophthalmology. Aug 1985;92(8):1075-83. [Medline].

  36. Margo CE, Polack FM, Hood CI. Aspergillus panophthalmitis complicating treatment of pterygium. Cornea. 1988;7(4):285-9. [Medline].

  37. Morgan KS, Asbell PA, McDonald MB, May JG, Loupe DN, Kaufman HE. Preliminary visual results of pediatric epikeratophakia. Arch Ophthalmol. Oct 1983;101(10):1540-4. [Medline].

  38. Nelson JD, Williams P, Lindstrom RL, Doughman DJ. Map-fingerprint-dot changes in the corneal epithelial basement membrane following radial keratotomy. Ophthalmology. Feb 1985;92(2):199-205. [Medline].

  39. Ohashi Y, Matsuda M, Hosotani H, Tano Y, Ishimoto I, Fukuda M, et al. Aldose reductase inhibitor (CT-112) eyedrops for diabetic corneal epitheliopathy. Am J Ophthalmol. Mar 15 1988;105(3):233-8. [Medline].

  40. Pflugfelder SC, Saulson R, Ullman S. Peripheral corneal ulceration in a patient with AIDS-related complex. Am J Ophthalmol. Nov 15 1987;104(5):542-3. [Medline].

  41. Portnoy SL, Insler MS, Kaufman HE. Surgical management of corneal ulceration and perforation. Surv Ophthalmol. Jul-Aug 1989;34(1):47-58. [Medline].

  42. Pérez-Santonja JJ, Bellot J, Claramonte P, Ismail MM, Alió JL. Laser in situ keratomileusis to correct high myopia. J Cataract Refract Surg. Apr 1997;23(3):372-85. [Medline].

  43. Quillen DA, Rosenwasser GO. Aerosol application of cyanoacrylate adhesive. J Refract Corneal Surg. Mar-Apr 1994;10(2):149-50. [Medline].

  44. Refojo MF, Dohlman CH, Ahmad B, Carroll JM, Allen JC. Evaluation of adhesives for corneal surgery. Arch Ophthalmol. Nov 1968;80(5):645-56. [Medline].

  45. Rosenbery S. Corneal dellen following contact-lens wear. Am J Ophthalmol. Jun 1969;67(6):970. [Medline].

  46. Roy FH. Ocular Differential Diagnosis. 4th ed. Philadelphia: Lea and Febiger; 1984.

  47. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S, et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology. Nov 1992;99(11):1647-54. [Medline].

  48. Schwartz DE. Corneal sensitivity in diabetics. Arch Ophthalmol. Mar 1974;91(3):174-8. [Medline].

  49. Shivitz IA, Arrowsmith PN. Delayed keratitis after radial keratotomy. Arch Ophthalmol. Aug 1986;104(8):1153-5. [Medline].

  50. Smith RE, Schanzlin DJ. Rheumatoid diseases. In: Smolin, Thoft, eds. The Cornea: Scientific Foundations and Clinical Practice. 2nd ed. Boston: Little, Brown & Co; 1997.

  51. Smith SG, Lindstrom RL, Nelson JD, Weiss JL, Doughman DJ. Corneal ulcer-infiltrate associated with soft contact lens use following penetrating keratoplasty. Cornea. 1984;3(2):131-4. [Medline].

  52. Soong HK, Quigley HA. Dellen associated with filtering blebs. Arch Ophthalmol. Mar 1983;101(3):385-7. [Medline].

  53. Stern GA, Weitzenkorn D, Valenti J. Adherence of Pseudomonas aeruginosa to the mouse cornea. Epithelial v stromal adherence. Arch Ophthalmol. Dec 1982;100(12):1956-8. [Medline].

  54. Swinger CA, Villasenor RA. Homoplastic keratomileusis for correction of myopia. J Refr Surg. 1985;1:219-23.

  55. Townsend WM. Corneal melt after cataract surgery. Conjunctival flaps. In: The Cornea. New York: Churchill Livingstone; 1988:669.

  56. Vitrectomy with silicone oil or perfluoropropane gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. Silicone Study Report 2. Arch Ophthalmol. Jun 1992;110(6):780-92. [Medline].

  57. Vitrectomy with silicone oil or sulfur hexafluoride gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. Silicone Study Report 1. Arch Ophthalmol. Jun 1992;110(6):770-9. [Medline].

  58. Waring GO 3rd, Lynn MJ, Gelender H, Laibson PR, Lindstrom RL, Myers WD, et al. Results of the prospective evaluation of radial keratotomy (PERK) study one year after surgery. Ophthalmology. Feb 1985;92(2):177-98, 307. [Medline].

  59. Weiss JL, Williams P, Lindstrom RL, Doughman DJ. The use of tissue adhesive in corneal perforations. Ophthalmology. Jun 1983;90(6):610-5. [Medline].

  60. Wilhelmus KR. Corneal edema following argon laser iridotomy. Ophthalmic Surg. Aug 1992;23(8):533-7. [Medline].

  61. Wilhelmus KR, Hamburg S. Bacterial keratitis following radial keratotomy. Cornea. 1983;2:143-6.

  62. Zabel RW, MacDonald IM, Mintsioulis G. Corneal endothelial decompensation after argon laser iridotomy. Can J Ophthalmol. Dec 1991;26(7):367-73. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

postoperative corneal melt, corneal melting, corneal perforation, corneal scarring, corneal epithelial defect, corneal tissue, corneal ulcer, corneal ulceration, cornea, vision loss

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Arun Verma, MD, Senior Consultant, Department of Ophthalmology, Dr Daljit Singh Eye Hospital, India
Disclosure: Nothing to disclose.

Medical Editor

Richard W Allinson, MD, Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center, Scott and White Clinic
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.