OBJECTIVE: We describe the management of a case of severe corneal melting after corneal cross-linking (CXL) treated with a staged approach using a conjunctival flap followed by deep anterior lamellar keratoplasty (DALK).
METHODS: A 12-year-old male developed severe corneal melting with pending perforation after an accelerated epithelium-off CXL protocol. We initially treated the patient with a conjunctival flap to prevent perforation. Three months later, we performed DALK to restore vision.
RESULTS: Conjunctival flap surgery allowed us to avoid corneal perforation and penetrating keratoplasty (PK) à chaud. Once the inflammation had resolved, we recessed the conjunctiva and performed DALK for optical purposes. Twelve months later, the graft was clear and the corrected visual acuity was 20/25 (Snellen). No complications occurred after surgery.
CONCLUSIONS: Although CXL is considered a safe procedure, in rare cases it can lead to serious complications, such as corneal haze, infectious and non-infectious keratitis, stromal melting and perforation. Corneal melting and perforation are usually managed by emergency PK. Herein we suggest a staged approach involving an emergency conjunctival flap followed by DALK at a later time that allowed us to avoid PK à chaud.

Background: Boston Keratoprosthesis Type I (BI-KPro I) is a synthetic cornea that can be used to restore vision in patients with corneal blindness. This retrospective study evaluated the outcomes of BI-KPro implantation in 118 patients. Material: The mean age of the patients was 56.76 ± 14.24 years. Indications for keratoprosthesis implantation were as follows: graft failure, 47 (39.83%); ocular burn, 38 (32.20%); neurotrophic keratopathy, 11 (9.32%), mucous membrane pemphigoid 9 (7.67%); autoimmune, 6 (5.08%); Stevens-Johnson syndrome, 4 (3.39%); and aniridia (2.54%). Methods: The surgeries were performed between March 2019 and June 2022 at a single clinical center in two locations. The postoperative visual acuity, complications, and need for additional surgical procedures were analyzed. Results: The Best Corrected Visual Acuity before surgery was 0.01 ± 0.006. After one year (V1), it was 0.30 ± 0.27; at two years (V2), it was 0.27 ± 0.26; and at three years (V3), it was 0.21 ± 0.23. The percentage of patients with visual acuity better than 0.1 on the Snellen chart was 37.29% after 1 year, 49.35% after 2 years, and 46.81% after 3 years of follow up. The most common complications were glaucoma (78 patients; 66.1%), corneal melting (22 patients; 18.6%), and retroprosthetic membranes (20 patients; 17.0%). Conclusions: The BI-KPro can significantly improve visual acuity. The worst long-term results were obtained in the group of patients with autoimmune diseases; therefore, careful consideration should be given to implanting BI-KPro in this group. The high incidence of de novo glaucoma or the progression of pre-existing glaucoma suggests the need for careful monitoring.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed perioperatively to reduce intraoperative prostaglandin release, diminishing pain, preventing miosis, modulating postoperative inflammation, and reducing the incidence of cystoid macular edema (CME).
METHODS: A 70-year-old female patient without previous history of ocular or systemic disease was urgently referred to our hospital because of a sudden corneal perforation concerning her left eye (OS). The patient had instilled bromfenac eye drops and antiseptic eye drops twice and four times daily, respectively, for 2 days only, in preparation of scheduled cataract surgery. Slit-lamp examination revealed diffuse inferior corneal melting with a 1 × 2 mm area of full-thickness perforation and a very shallow anterior chamber. Both topical agents were immediately discontinued. Cyanoacrylate glue was applied to seal the perforation and a bandage contact lens was applied together with a topical antibiotic given hourly. Two hours later, the anterior chamber started to reform. The following day, the anterior chamber was fully reformed with a negative Seidel test. At her next follow-up appointment, 1 month later, the glue was detached and the cornea was seen to have successfully healed with only some corneal thinning remaining inferiorly.
CONCLUSIONS: Perioperative use of topical NSAIDs in combination with antiseptic eye drops may rarely elicit corneal perforation in certain susceptible elderly individuals. Their use should therefore be carefully monitored.

UNASSIGNED: Corneal perforation due to severe melting is a very dangerous, sight-threatening condition requiring immediate management due to the high risk of endophthalmitis and critical hypotony. In the case of perforated corneal grafts, retransplantation is usually postponed to avoid the detrimental effects of inflammation on the new graft. We describe the first case of the use of a TutoPatch graft for emergency replacement of a lamellar graft perforation over acute infectious total melting.
UNASSIGNED: A 42-year-old male patient presented to the Emergency Department with pain in the left eye, which was red photophobic. He had been treated with bilateral deep anterior lamellar keratoplasty (DALK) for advanced keratoconus 5 years previously and had been experiencing recurrent corneal ulcers in the left eye within the last 8 months. Clinical examination documented corneal perforation over acute infectious melting involving the total graft surface in the left eye. The infected graft was removed along with the perforated infected residual Descemet membrane, and a double-layer TutoPatch covering was sutured to the host\'s margin with 10.0 nylon. The covering was left in place for three weeks, allowing the patient to undergo retransplant three weeks later without complications.
UNASSIGNED: TutoPatch covering can be safely used as an easy-to-preserve emergency material for a temporary bridge to retransplantation in large acute infectious corneal melting.

Purpose: To present the case of a patient with a history of trauma and corneal foreign body in the right eye, followed by decreased visual acuity in the right eye, corneal perforation with good recovery after surgical treatment. Material and method: We report a case of a patient who presented to our clinic with a sudden decrease of visual acuity in the right eye, two months after an incident resulting in a corneal foreign body in the right eye. In the case presented, the patient applied a local medical self-treatment, an antibiotic and a topical corticosteroid. After a few weeks, the patient presented to the ophthalmologist, a foreign body was extracted from the cornea of the right eye and a topical treatment with a non-steroidal anti-inflammatory drug, a cycloplegic and an antibiotic were indicated. However, corneal perforation occurred and the patient was urgently sent to our service, where a corneal anaesthesia was also found. Results: Corneal perforation healed with a minor paracentral opacification. Discussions: Corneal perforation in our patient was due to corneal melting because of topical steroid anti-inflammatory autotherapy, late corneal foreign body extraction and topical treatment with non-steroidal anti-inflammatory drugs. Corneal anesthesia is also an important factor that enhances corneal melting and perforation. The surgical intervention performed healed the corneal perforation. Conclusions: Corneal anaesthesia and topical anti-inflammatory administration led to corneal perforation. Corneal sensitivity should be tested in patients with corneal foreign body. Corneal patching proved to be an adequate solution in this patient.

Trastuzumab is the cornerstone treatment for HER2-positive breast cancer. While ocular side effects are more commonly described after the use of the antibody-drug conjugate ado-trastuzumab emtansine, we here describe corneal melting in a 79-year-old patient after three cycles of trastuzumab monotherapy. Signs and symptoms persisted with subsequent trastuzumab cycles. The patient showed improvement after treatment with intense lubrication, topical antibiotics, and topical steroids. After tapering of steroids, there was recurrence of epitheliopathy after subsequent trastuzumab treatment, which subsided upon restarting topical steroids. Finally, the patient was kept on a low-dose topical steroid regimen which prevented further epitheliopathy during the next trastuzumab cycles.

BACKGROUND: PACK-CXL (photo-activated chromophore for keratitis-corneal cross-linking) is an alternative option in treatment of corneal infections. It inhibits corneal melting by increasing the stromal resistance, besides the microbicidal effect of photo-activated riboflavin.
METHODS: Corneal infection with Pseudomonas aeruginosa and Staph aureus bacteria was induced in 20 eyes of 10 rabbits after 6 weeks of corneal cross-linking in half of the eyes, while the other acted as control group. Clinical and corneal histopathological examination was done to evaluate the extent of inflammation, ulceration, organism penetration, and depth of corneal stromal affection.
RESULTS: The control eyes developed severe inflammation compared to the cross-linked eyes. Corneal melting occurred in 6 eyes in the control versus none in cross-linked group. Histopathological examination showed that the inflammation was confined to the superficial part of the stroma with localization of the inflammation in the cross-linked eyes in contrast to the control eyes that showed deep infiltration.
CONCLUSIONS: PACK-CXL provides infection localization through increasing the corneal rigidity and resistance to enzymatic digestion, even in the absence of the riboflavin microbicidal role. So, early PACK-CXL is worth to be considered in the IK treatment algorithm.

UNASSIGNED: Postoperative extrusion of an intraocular lens at a site unrelated to the surgical incision is a very rare complication. We report the case of a posterior chamber intraocular lens extrusion through the cornea eight years after a penetrating keratoplasty in a patient with spontaneous aseptic stromal melting.
UNASSIGNED: A 77-year-old man was treated for pseudophakic bullous keratopathy with a penetrating keratoplasty complicated by chronic graft rejection and severe glaucoma. He referred to our emergency department eight years after the surgery. The examination showed that the pseudophakic lens optic had eroded completely through the donor cornea. The globe remained intact during the extrusion process. The patient underwent excision of the pre-intraocular lens tissue, removal of intraocular lens implant and capsular bag, liberation of synechia, anterior vitrectomy and corneal graft under general anesthesia. There was no complication during or after the surgery. Histologic study suggests that the intraocular lens optic was covered by conjunctival epithelium with malpighian metaplasia.
UNASSIGNED: To our knowledge, it\'s the first case of posterior chamber intraocular extrusion through ocular tissues following penetrating keratoplasty. This case emphasizes the importance of early identification of risk factors, strong postoperative follow up and good patient compliance and the need to minimize drug and surgery-induced iatrogenic effects. If the complication does ensue, early surgical intervention may prevent or minimize serious damage.

UNASSIGNED: To report the tectonic role of circular and square-shaped lamellar grafts without using extra corneas.
UNASSIGNED: We retrospectively reviewed 23 lamellar patch grafts performed over a six-year period for various tectonic indications in corneal thinning and perforations. The anterior stroma of corneal endothelium peeled for Descemet Membrane Endothelial Keratoplasty were used to prepare circular lamellar corneal grafts. After punch trepanation of donor corneas for penetrating keratoplasty, the remaining rim of the cornea was used to prepare square-shaped grafts.
UNASSIGNED: Circular lamellar grafts were used in 13 eyes that had paracentral or central corneal thinning or perforations. Square-shaped grafts were used in 10 eyes, nine of which had peripheral corneal thinning or perforations, and one, limbal. Anatomical success after tectonic grafts was achieved in 22 of 23 eyes (95.6%) at a mean follow-up of 9.83 ± 6.27 months. The mean of the best-corrected visual acuity improved from logMAR 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 postoperatively, at the final follow-up.
UNASSIGNED: The main disadvantage of patch grafts is the shortage in corneal supply due to insufficient cornea donation in developing countries like Turkey. By evaluating unused corneal rims, extra corneas will not be required.

Dry eye syndrome is a common multifactorial disorder of the tear film and ocular surface. In rare cases, it may be caused by systemic diseases. Corneal melting is a complication of dry eye syndrome and is a potentially blinding condition. Here we report a case of a 67-year-old patient who attended her general practitioner for a year complaining of persistent dry eyes. Ophthalmological assessment showed severe dry eye syndrome with cornea melting in left eye. Blood test revealed anaemia and thrombocytopenia with circulating blasts. Bone marrow biopsy showed 15% myeloblasts with monosomy 7, compatible with acute myeloid leukaemia. Patient was started on intensive chemotherapy regime and was a candidate for allogenic bone marrow transplant. To our knowledge, this is the first case report demonstrating dry eye syndrome with sterile corneal melting as the possible presenting complaints of acute myeloid leukaemia. This case will serve as a useful reminder to general practitioners and accident and emergency doctors about the current guidelines regarding referral of persistently symptomatic patients with dry eye syndrome for further investigation in secondary care.