Late corneal perforation after photorefractive keratectomy associated with topical diclofenac: Involvement of matrix metalloproteinases

doi:10.1016/S0161-6420(03)00486-X

Ophthalmology

Volume 110, Issue 8, August 2003, Pages 1626-1631

Presented at the meeting of the Association for Research in Vision and Ophthalmology, Ft. Lauderdale, Florida, May 2002.

https://doi.org/10.1016/S0161-6420(03)00486-X Get rights and content

Abstract

Objective

To report a case of a 50-year-old man who was initially seen with a corneal perforation in his right eye 2 months after a photorefractive keratectomy (PRK) procedure and to discuss the roles of topical diclofenac and matrix metalloproteinases (MMPs).

Design

Case report with tissue analysis.

Main outcome measures

Ocular examination, diagnostic workup, surgical treatment, and histologic, immunofluorescent, zymography, and real time-polymerase chain reaction studies on corneal button.

Results

Slit-lamp examination of the right eye revealed a 4-mm diameter area of central corneal thinning with a 2-mm diameter perforation at its center. Predisposing factors included prolonged postoperative topical diclofenac therapy for more than 2 months and a 10-year history of well-controlled diabetes mellitus. An extensive diagnostic workup ruled out a systemic autoimmune disease. A penetrating keratoplasty was performed. Results of immunohistochemical studies of the corneal button showed stromal accumulation of temporary type III and IV collagens, MMP-3, and MMP-9 in the anterior wounded stroma and MMP-9 in the basal corneal epithelial cells of the leading edge. Differential activity and expression of MMP-2 and MMP-9 were found between the central and peripheral corneal buttons.

Conclusions

Prolonged use of diclofenac and diabetes mellitus might be responsible for the corneal perforation after PRK in our patient. MMP-9 and MMP-3 might be involved in delayed wound closure and corneal melting.

Section snippets

Case report

A 50-year-old man was referred to the authors in September 2001 for a corneal perforation of his right eye, 2 months after an uneventful PRK. Medical and ophthalmologic history was noncontributive for diseases, surgeries, or injuries associated with decreased corneal sensitivity or abnormal corneal irritation or exposure. The only remarkable feature was noninsulin-dependent diabetes mellitus, which was well controlled for the past 10 years. Preoperatively, the right eye had an anisometropic

Results

Histopathologic examination disclosed a markedly thickened corneal epithelium with absence of Bowman’s layer on an area of dramatic thinning of the corneal stroma (Fig 2).

Immunohistochemical examination revealed types III and IV collagens in the treated stroma (Fig 3). In addition, MMP-3 and MMP-9 were detected in the anterior wounded stroma, particularly in the subepithelial layer (Fig 4A- C), although MMP-9 also was seen in the basal epithelial cells of the leading edge (Fig 4C).

Five bands

Discussion

We report herein a case of corneal perforation after PRK in a patient with nonkeratoconus. Corneal perforation is a rare complication of refractive surgery, and has been reported during radial keratotomy, intracorneal ring segment implantation, and recently LASIK.21, 22, 23 We believe that the prolonged postoperative use of topical diclofenac in our patient played a role in the pathogenesis of this complication, because this drug has already been associated with corneal ulcerations and

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A total of 70 patients completed at least 1 postoperative visit and were included. There was no statistically significant difference between the treatment eye and the no treatment eye in any of the studied parameters.
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Manuscript no. 220731.

Supported by the Association Française des Amblyopes Unilatéraux, Paris, France.

None of the authors has any commercial interest that could cause or be perceived to be a conflict of interest.

View full text

Late corneal perforation after photorefractive keratectomy associated with topical diclofenac: Involvement of matrix metalloproteinases☆

Abstract

Objective

Design

Main outcome measures

Results

Conclusions

Section snippets

Case report

Results

Discussion

Ophthalmology

J Cataract Refract Surg

J Cataract Refract Surg

Ophthalmology

J Biol Chem

Am J Pathol

Surv Ophthalmol

Ophthalmology

J Cataract Refract Surg

Ophthalmology

Ophthalmology

The treatment of pain following photorefractive keratectomy

J Refract Corneal Surg

A prospective randomized trial of topical soluble 0.1% indomethacin versus 0.1% diclofenac versus placebo for the control of pain following excimer laser photorefractive keratectomy

Ophthalmic Surg Lasers

The effect of steroidal and nonsteroidal anti-inflammatory agents on corneal re-epithelialization

Invest Ophthalmol Vis Sci

Topical diclofenac sodium after excimer laser phototherapeutic keratectomy

J Refract Surg