When the Cornea Melts

Everyone has their own favorite workplace story to tell their friends. In the case of this particular Media MICE writer, that story happens to revolve around corneal melting. When he started out working for the world’s funkiest ophthalmology collective, he covered the ESCRS Winter Meeting in 2021 and wrote a report about a case study involving a 31-year-old Portuguese patient with severe Crohn’s disease. 

So severe, in fact, that it had not only caused gangrene and multiple recurring perianal abscesses (yes, really) … but also because it also caused corneal melting to the extent that the patient’s pupil appeared to bleed out of the patient’s eye.

Normally the reaction received for this little story is abject revulsion (and shock) that this is medically possible. We in the ophthalmology community of course know better, so when a chance came around to write about corneal melts again, then the editor naturally took the chance to assign the article to yours truly again. Thank goodness for Dr. Julie Schallhorn, an associate professor of ophthalmology at the University of California, San Francisco, for her presentation Differentiating and Treating Inflammatory Melts.

Pucker Up for PUK

Given during the American Society of Cataract and Refractive Surgery (ASCRS) annual meeting in Washington D.C. earlier this year, Dr. Schallhorn’s presentation was marvelously melty and monstrously fact-filled. It began with an outline of the most common causes of scleritis and peripheral ulcerative keratitis (PUK) at the presentation stage. She reported that these are infections in 7% of cases; autoimmune issues in another 37% of cases; and in the remaining 66%, no cause could be defined. However, in the final category, up to 50% of patients will be diagnosed with an autoimmune disease within a 90-month period.

Going into a little more detail about the infections that most commonly cause corneal melts, one can find the usual suspects like bacterial and fungal issues, but also syphilis, a certain writer’s favorite topic. Many autoimmune conditions were listed by Dr. Schallhorn as causing scleritis and PUK, including Crohn’s in the form of inflammatory bowel disease, as well as other less suspected causes like hepatitis and polyangiitis. Rather ironically given that our correspondent was writing this article from Istanbul, Turkey, the incredibly rare Behcet’s disease was also listed, a rather nasty condition that causes inflammation in the blood.

We’ve covered reports from other conferences about how to effectively communicate with patients and that was a trend picked up by Dr. Schallhorn too, specifically about the subtle risk factors for corneal melts. So, if your patient comes to your clinic and also exhibits non-ocular warning signs, ranging from oral and genital ulcers, to arthritis and blood in the stool, talk to them about their medical background. You may well find that they have other risk factors of scleritis and PUK.

Mesmerizingly Melty Melts

Once you’ve got all of that out of the way, you’ve established a melty diagnosis and are ready to crack on with actually treating the cornea, Dr. Shallhorn had a number of other recommendations, too. 

She said that the endpoint has to be the complete epithelialization of the defect, along with a quiet sclera. Furthermore, she emphasized that treatment must depend on etiology, and that one should engage with rheumatology, infectious disease and uveitis specialists when required.

Dr. Schallhorn described how she preferred to take a conservative approach as much as possible, and that one should not be too eager to resort to patching. In fact, she said that in cases where the melt is small, surgery is not the answer, and that it is better to focus on treating the underlying cause of the problem. Her mantra could be summed up as “only patch when you must.”

But when it comes down to patching, Dr. Schallhorn was happy to share how she aims at getting those patches perfect, starting with smaller ones where she tends to use a <4-5 mm circular punch. For larger areas, you’ll want to use a >5-6mm crescentic graft instead, according to our doctor. Here again however, she emphasizes the importance of a conservative approach and only intervening when necessary.

In summary, we can say a few things, firstly that we really enjoyed this presentation — so, if you didn’t make it to ASCRS 2022 you certainly missed out on this one! Dr. Schallhorn, in her own concluding remarks, added that one should use “glue if perforated, patch if necessary” in treating corneal melts, and that conjunctival resection can be a useful adjuvant. As for our writer, he’s just happy he’s got another corneal melt story to tell…

Editor’s Note: ASCRS 2022 was held on April 22-26, as a physical show in Washington D.C., USA. Reporting for this story took place during the event.

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