A Case-Based Approach to the Management of Corneal Melts and Perforations in Ocular Surface Disorders

Abstract

Corneal perforations caused by chronic ocular surface disorders present significant management challenges and can lead to blindness if untreated. This case series reviews the pathophysiology of corneal melts and examines treatment strategies tailored to the size, location, and etiology of perforations in conditions such as Stevens-Johnson syndrome, graft-versus-host disease, and chemical injuries. Through detailed case analyses, various interventions, including cyanoacrylate glue, Tenon's patch grafting, mucous membrane grafts, scleral patch grafts, and conjunctival flaps, were evaluated, along with emerging therapies like biosynthetic hydrogels and collagen-like peptides. Findings highlight the role of chronic inflammation and adnexal abnormalities in disrupting ocular surface integrity, affecting treatment outcomes. This case series underscores the importance of a comprehensive approach that not only repairs corneal defects but also addresses underlying systemic and ocular conditions, with advancements in biosynthetic materials showing promise for improving patient outcomes.

Keywords: chronic inflammation; corneal perforation; limbal stem cell deficiency (lscd); ocular surface disorders; visual rehabilitation.

Figure 1. Inferior corneal melt with a pinpoint leak and iris prolapse

Figure 2. Steps of cyanoacrylate tissue adhesive (CTA) with bandage contact lens (BCL)

(A-C): Debridement of loose epithelium with forceps and cauterization if needed; (D-E): application of CTA with the back of merocele sponge on the de-epithelized cornea; (F): BCL placed

Figure 3. Steps of drape tissue adhesive with bandage contact lens (BCL)

(A): stromal bed prepared; (B, C): 3*3 mm sterile drape applied with tissue adhesive; (D) BCL placed

Figure 4. One-month post-drape tissue adhesive with bandage contact lens (BCL), inferior corneal melt with intraocular lens (IOL) extrusion noted

Figure 5. (A): Central 3 mm perforation with surrounding 7 mm thinning; (B): One month post Tenon's patch graft

Figure 6. Surgical steps of surface mucous membrane grafting

(A): Symblepharon release done, pannus over the central cornea was left in situ; (B) Harvested oral mucosa from the lower lip; (C) multiple partial-thickness vertical incisions made to increase the surface area of the mucosal graft; (D-F): Graft secured to the host tenons with 7-0 vicryl sutures at the four recti and conjunctiva to ensure proper vascular supply of the graft

Figure 7. Three months post surface mucous membrane grafting.; ocular surface stable

Figure 8. Surgical steps of the scleral patch graft

(A): 4*3mm paracentral perforation at the graft host junction; (B-D): measurement and preparation of the scleral rim of the required size; (E, F): Rim sutured to the host sclera and cornea with 10-0 nylon sutures; (G, H): Amniotic membrane placed over the entire ocular surface with fibrin glue

Figure 9. Surgical steps of a conjunctival flap

(A) Pericylindrical melt in keratoprosthesis; (B, C) Conjunctival peritomy done nasally and temporally; (D-F): Conjunctiva mobilized 360 degrees; (G, H): Superior and inferior forniceal conjunctiva separated from the tenon capsule; (I-L): Conjunctiva sutured over the keratoprosthesis with 6-0 vicryl sutures

Figure 10. Two years post conjunctival flap for pericylindrical melt; stable ocular surface