Case Report: Corneal Melt Secondary to Chronic Ocular Surface Disease

Case at a Glance

A 41-year-old female with a known history of chronic Meibomian Gland Dysfunction (MGD) and blepharitis presented with a non-healing corneal epithelial defect that had progressed to stromal thinning, consistent with corneal melt (keratolysis).

Patient's Story

The patient, a 41-year-old female, has a long-standing history of ocular surface disease, including MGD and blepharitis. These chronic conditions recently led to the development of a corneal erosion that was slow to heal. Despite initial management, her condition worsened, culminating in what her treating physician described as 'keratomalacia.' Facing significant pain and concerned about her diagnosis, the patient sought further opinions and expressed desperation regarding her treatment options.

Initial Assessment

On presentation, the patient was experiencing ocular pain and likely had significantly reduced visual acuity in the affected eye. Clinical examination findings, interpreted from provided images, revealed:

• Lids and Lashes: Evidence consistent with chronic blepharitis and Meibomian Gland Dysfunction.
• Conjunctiva: Moderate to severe conjunctival injection (redness).
• Cornea: A large, central, irregular epithelial defect was noted, which stained brightly with fluorescein dye. Underlying the defect was significant stromal haze and apparent thinning, characteristic of corneal melt (keratolysis). There were no clear signs of a suppurative infiltrate, suggesting a primarily inflammatory or sterile process rather than an active bacterial keratitis, though secondary infection remained a high risk.

The Diagnostic Journey

The patient's diagnostic path began with the management of chronic ocular surface disease. The failure of the corneal epithelium to heal led to a persistent epithelial defect (PED). Such defects can release collagenases and other proteolytic enzymes, leading to the breakdown of the underlying corneal stroma. The clinical diagnosis of corneal melt was confirmed by the slit-lamp finding of stromal loss beneath the epithelial defect, highlighted by fluorescein staining. While the patient was told she had keratomalacia (a condition typically associated with severe vitamin A deficiency), the clinical picture was more consistent with sterile keratolysis secondary to chronic inflammation from her underlying ocular surface disease.

Final Diagnosis

Sterile Corneal Melt (Keratolysis) with a large Persistent Epithelial Defect, secondary to Chronic Blepharitis and Meibomian Gland Dysfunction.

Treatment Plan

The patient was initiated on a multi-faceted treatment plan aimed at reducing inflammation, preventing infection, managing pain, and promoting healing:

1. Prophylactic Antibiotic: Tobrex (tobramycin) ophthalmic ointment to be applied to prevent secondary bacterial infection of the exposed corneal stroma. The ointment base also provides a lubricating and protective layer.
2. Systemic Anti-inflammatory: Celebrex (celecoxib), a systemic NSAID, prescribed twice daily to manage ocular and systemic inflammation and control pain.
3. Intraocular Pressure (IOP) Control: Timolol ophthalmic solution was prescribed to lower IOP, likely as a prophylactic measure against inflammatory glaucoma.
4. Patient-Initiated Therapy: The patient reported self-administering one drop of Moxidexa (moxifloxacin-dexamethasone).
   • Clinical Note: The use of a potent steroid like dexamethasone on a melting cornea is highly controversial and potentially dangerous, as it can inhibit healing and worsen stromal loss. This requires immediate and careful assessment by the managing ophthalmologist.

Outcome and Follow-up

The outcome is pending. The patient presented at a critical juncture, seeking alternative management strategies. The immediate goals of therapy are to halt the progression of the melt, prevent corneal perforation, and support re-epithelialization. Aggressive lubrication with preservative-free artificial tears and potential use of autologous serum eye drops would be critical. Further interventions, such as a bandage contact lens, amniotic membrane transplantation, or surgical procedures like a tarsorrhaphy (partially suturing the eyelid closed) or a conjunctival flap, may be necessary if the melt does not stabilize. The patient requires urgent and frequent follow-up with a cornea specialist to monitor for response to treatment and to manage the risks associated with her condition and self-initiated steroid use.