Keratolysis, or sterile melting of the cornea (Fig 11-1), may occur after cataract extraction. It is most frequently associated with preexisting tear film abnormalities resulting from keratoconjunctivitis sicca and autoimmune diseases such as Sjögren syndrome, rheumatoid arthritis, or graft-vs-host disease. Keratitis may be exacerbated by the chemical or mechanical stress of surgery or the topical medications used perioperatively.
Figure 11-1 Corneal melt.
(Courtesy of Thomas L. Steinemann, MD.)
Stromal melting has been reported with the postoperative use of topical nonsteroidal anti-inflammatory drugs (NSAIDs), due in part to the epithelial toxicity and hypoesthesia that these drugs can induce. NSAID-associated stromal melting is more likely to occur in patients with keratoconjunctivitis sicca, systemic autoimmune disease, or collagen vascular disease.
Frequent perioperative use of nonpreserved topical lubricants, punctal plug placement, or lateral tarsorrhaphy may lessen morbidity in eyes with preexisting tear film abnormalities. Persistent epithelial defects accompanied by stromal dissolution require intensive treatment with nonpreserved topical lubricants. It is important to minimize the use of preserved topical medications to reduce their toxic effect on the corneal epithelium. Additional treatments to encourage epithelialization and arrest stromal melting include punctal occlusion, bandage contact lenses, autologous serum eyedrops, collagenase inhibitors such as acetylcysteine 10% or hydroxyprogesterone 1%, and systemic matrix metalloproteinase inhibitors such as doxycycline.
If the disease continues to progress despite medical therapy, a commercially available temporary amniotic membrane graft may be considered. In advanced recalcitrant cases, lamellar or penetrating keratoplasty may be necessary. Corneal melting may recur even with grafted tissue. For the treatment of any underlying autoimmune disease, systemic immunosuppressive therapy may be necessary.
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.