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Four cases of corneal perforation in patients with chronic graft-versus-host disease.

Inagaki E, Ogawa Y, Matsumoto Y, Kawakita T, Shimmura S, Tsubota K - Mol. Vis. (2011)

Bottom Line: Three patients were successfully treated by corneal transplantation.One patient was treated with a therapeutic soft contact lens, and the wound healed within 2 days.Immunohistochemical findings revealed an increased number of cluster of differentiation 68(+) (CD68(+)) macrophages and matrix metalloproteinase 9 (MMP-9) expression in the tissue surrounding the perforation.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan.

ABSTRACT

Purpose: To report the clinical features and investigate the underlying pathological processes of spontaneous corneal perforation in patients with ocular chronic graft-versus-host disease (cGVHD).

Methods: A full ophthalmological evaluation of corneal perforation in four patients with cGVHD was performed. Three of them underwent deep anterior lamellar keratoplasty and samples from two of three patients were used for histopathological analyses.

Results: Three patients were successfully treated by corneal transplantation. One patient was treated with a therapeutic soft contact lens, and the wound healed within 2 days. The common clinical features of these patients were (1) the presence of definite dry eye related to cGVHD in 3 of 4 patients and probable dry eye in one patient, (2) a central or paracentral site of corneal ulceration and perforation, with no sign of infection, and (3) prior use of a topical or systemic corticosteroid, and/or topical non-steroidal anti-inflammatory drugs. Immunohistochemical findings revealed an increased number of cluster of differentiation 68(+) (CD68(+)) macrophages and matrix metalloproteinase 9 (MMP-9) expression in the tissue surrounding the perforation.

Conclusions: Our report extends current information on the clinical features and pathological processes of corneal perforation in cGVHD by showing increased MMP-9 expression and the accumulation of CD68(+) positive macrophages in the affected areas.

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Related in: MedlinePlus

Clinical findings of perforated cornea before and after treatment with deep anterior lamellar keratoplasty or glue. A, B: Case 1 photographs of the perforated cornea upon admission (left eye). A: The perforation was located in the paracentral cornea. The size of the perforation was 0.5 mm×0.5 mm. The surrounding ulcer was 2.0 mm×1.5 mm. B: Preoperative photo showing a positive Seidel test. C: Photograph of the cornea after deep anterior lamellar keratoplasty. Five months later, the corneal graft remained stable and transparent. D, E: Case 2 slit lamp photograph taken upon admission (right eye). D: The perforation was in the paracentral cornea and was 0.5 mm×1.0 mm. E: Photograph showing the paracentral corneal perforation plugged by the iris. F: Slit lamp photograph after the operation. One year after deep anterior lamellar keratoplasty, the corneal graft was stable and transparent. G, H: Case 3 slit lamp photograph taken upon admission (left eye). G: The perforation was inferior to the center of the cornea and was 0.5 mm×0.5 mm. An ulcer (2.0 mm×1.0 mm) was observed inferiorly. H: The anterior chamber was maintained by the prolapsed iris. I: Slit lamp photograph 3 months after healing of the perforated cornea without surgical intervention. J: Case 4 slit lamp photograph taken upon admission (right eye). The perforation was located inferior to the center of the cornea. The cornea was 3.5 mm×1.5 mm, and the perforation was 2.0 mm×1.0 mm. The Seidel test was positive.
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f1: Clinical findings of perforated cornea before and after treatment with deep anterior lamellar keratoplasty or glue. A, B: Case 1 photographs of the perforated cornea upon admission (left eye). A: The perforation was located in the paracentral cornea. The size of the perforation was 0.5 mm×0.5 mm. The surrounding ulcer was 2.0 mm×1.5 mm. B: Preoperative photo showing a positive Seidel test. C: Photograph of the cornea after deep anterior lamellar keratoplasty. Five months later, the corneal graft remained stable and transparent. D, E: Case 2 slit lamp photograph taken upon admission (right eye). D: The perforation was in the paracentral cornea and was 0.5 mm×1.0 mm. E: Photograph showing the paracentral corneal perforation plugged by the iris. F: Slit lamp photograph after the operation. One year after deep anterior lamellar keratoplasty, the corneal graft was stable and transparent. G, H: Case 3 slit lamp photograph taken upon admission (left eye). G: The perforation was inferior to the center of the cornea and was 0.5 mm×0.5 mm. An ulcer (2.0 mm×1.0 mm) was observed inferiorly. H: The anterior chamber was maintained by the prolapsed iris. I: Slit lamp photograph 3 months after healing of the perforated cornea without surgical intervention. J: Case 4 slit lamp photograph taken upon admission (right eye). The perforation was located inferior to the center of the cornea. The cornea was 3.5 mm×1.5 mm, and the perforation was 2.0 mm×1.0 mm. The Seidel test was positive.

Mentions: A 62-year-old man had been treated for acute myelogenous leukemia (AML; M4) with an allogeneic peripheral blood stem cell transplant from an human leukocyte antigen (HLA)-matched sibling in April, 2006. Six months later, he presented with severe dry eye related to cGVHD. The dry eye was treated at a local eye clinic with commercially available tear substitutes and punctal plug. In August, 2007, the subject exhibited a grouped vesicular eruption over dermatome V1 on his right forehead. Five days later, he developed superficial punctate keratitis, and uveitis in the right eye, and corneal erosion in the left eye. He was treated with topical eye medications that contained acyclovir (Santen Pharmaceutical Co. Ltd., Osaka, Japan), sodium hyaluronate, (Santen Pharmaceurical Co. Ltd, Osaka, Japan) and betamethasone sodium phosphate (Shionogi & Co., Ltd., Osaka, Japan) for both eyes and gatifloxacin hydrate (Senju Pharmaceutical Co., Ltd., Osaka, Japan) and 1% atropine sulfate (Nitten Pharmaceutical Co., Ltd., Nagoya, Japan) for the right eye. However, after 1 day of this treatment, the patient developed a central corneal perforation of the left eye (Figure 1A,B). Cyanoacrylate glue therapy was attempted, but failed on the following day. The perforation was then treated by DALK. Best-corrected visual acuity (BCVA) at the 6-month follow up was 20/200. The corneal graft attached well and was stable (Figure 1C).


Four cases of corneal perforation in patients with chronic graft-versus-host disease.

Inagaki E, Ogawa Y, Matsumoto Y, Kawakita T, Shimmura S, Tsubota K - Mol. Vis. (2011)

Clinical findings of perforated cornea before and after treatment with deep anterior lamellar keratoplasty or glue. A, B: Case 1 photographs of the perforated cornea upon admission (left eye). A: The perforation was located in the paracentral cornea. The size of the perforation was 0.5 mm×0.5 mm. The surrounding ulcer was 2.0 mm×1.5 mm. B: Preoperative photo showing a positive Seidel test. C: Photograph of the cornea after deep anterior lamellar keratoplasty. Five months later, the corneal graft remained stable and transparent. D, E: Case 2 slit lamp photograph taken upon admission (right eye). D: The perforation was in the paracentral cornea and was 0.5 mm×1.0 mm. E: Photograph showing the paracentral corneal perforation plugged by the iris. F: Slit lamp photograph after the operation. One year after deep anterior lamellar keratoplasty, the corneal graft was stable and transparent. G, H: Case 3 slit lamp photograph taken upon admission (left eye). G: The perforation was inferior to the center of the cornea and was 0.5 mm×0.5 mm. An ulcer (2.0 mm×1.0 mm) was observed inferiorly. H: The anterior chamber was maintained by the prolapsed iris. I: Slit lamp photograph 3 months after healing of the perforated cornea without surgical intervention. J: Case 4 slit lamp photograph taken upon admission (right eye). The perforation was located inferior to the center of the cornea. The cornea was 3.5 mm×1.5 mm, and the perforation was 2.0 mm×1.0 mm. The Seidel test was positive.
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Related In: Results  -  Collection

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f1: Clinical findings of perforated cornea before and after treatment with deep anterior lamellar keratoplasty or glue. A, B: Case 1 photographs of the perforated cornea upon admission (left eye). A: The perforation was located in the paracentral cornea. The size of the perforation was 0.5 mm×0.5 mm. The surrounding ulcer was 2.0 mm×1.5 mm. B: Preoperative photo showing a positive Seidel test. C: Photograph of the cornea after deep anterior lamellar keratoplasty. Five months later, the corneal graft remained stable and transparent. D, E: Case 2 slit lamp photograph taken upon admission (right eye). D: The perforation was in the paracentral cornea and was 0.5 mm×1.0 mm. E: Photograph showing the paracentral corneal perforation plugged by the iris. F: Slit lamp photograph after the operation. One year after deep anterior lamellar keratoplasty, the corneal graft was stable and transparent. G, H: Case 3 slit lamp photograph taken upon admission (left eye). G: The perforation was inferior to the center of the cornea and was 0.5 mm×0.5 mm. An ulcer (2.0 mm×1.0 mm) was observed inferiorly. H: The anterior chamber was maintained by the prolapsed iris. I: Slit lamp photograph 3 months after healing of the perforated cornea without surgical intervention. J: Case 4 slit lamp photograph taken upon admission (right eye). The perforation was located inferior to the center of the cornea. The cornea was 3.5 mm×1.5 mm, and the perforation was 2.0 mm×1.0 mm. The Seidel test was positive.
Mentions: A 62-year-old man had been treated for acute myelogenous leukemia (AML; M4) with an allogeneic peripheral blood stem cell transplant from an human leukocyte antigen (HLA)-matched sibling in April, 2006. Six months later, he presented with severe dry eye related to cGVHD. The dry eye was treated at a local eye clinic with commercially available tear substitutes and punctal plug. In August, 2007, the subject exhibited a grouped vesicular eruption over dermatome V1 on his right forehead. Five days later, he developed superficial punctate keratitis, and uveitis in the right eye, and corneal erosion in the left eye. He was treated with topical eye medications that contained acyclovir (Santen Pharmaceutical Co. Ltd., Osaka, Japan), sodium hyaluronate, (Santen Pharmaceurical Co. Ltd, Osaka, Japan) and betamethasone sodium phosphate (Shionogi & Co., Ltd., Osaka, Japan) for both eyes and gatifloxacin hydrate (Senju Pharmaceutical Co., Ltd., Osaka, Japan) and 1% atropine sulfate (Nitten Pharmaceutical Co., Ltd., Nagoya, Japan) for the right eye. However, after 1 day of this treatment, the patient developed a central corneal perforation of the left eye (Figure 1A,B). Cyanoacrylate glue therapy was attempted, but failed on the following day. The perforation was then treated by DALK. Best-corrected visual acuity (BCVA) at the 6-month follow up was 20/200. The corneal graft attached well and was stable (Figure 1C).

Bottom Line: Three patients were successfully treated by corneal transplantation.One patient was treated with a therapeutic soft contact lens, and the wound healed within 2 days.Immunohistochemical findings revealed an increased number of cluster of differentiation 68(+) (CD68(+)) macrophages and matrix metalloproteinase 9 (MMP-9) expression in the tissue surrounding the perforation.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan.

ABSTRACT

Purpose: To report the clinical features and investigate the underlying pathological processes of spontaneous corneal perforation in patients with ocular chronic graft-versus-host disease (cGVHD).

Methods: A full ophthalmological evaluation of corneal perforation in four patients with cGVHD was performed. Three of them underwent deep anterior lamellar keratoplasty and samples from two of three patients were used for histopathological analyses.

Results: Three patients were successfully treated by corneal transplantation. One patient was treated with a therapeutic soft contact lens, and the wound healed within 2 days. The common clinical features of these patients were (1) the presence of definite dry eye related to cGVHD in 3 of 4 patients and probable dry eye in one patient, (2) a central or paracentral site of corneal ulceration and perforation, with no sign of infection, and (3) prior use of a topical or systemic corticosteroid, and/or topical non-steroidal anti-inflammatory drugs. Immunohistochemical findings revealed an increased number of cluster of differentiation 68(+) (CD68(+)) macrophages and matrix metalloproteinase 9 (MMP-9) expression in the tissue surrounding the perforation.

Conclusions: Our report extends current information on the clinical features and pathological processes of corneal perforation in cGVHD by showing increased MMP-9 expression and the accumulation of CD68(+) positive macrophages in the affected areas.

Show MeSH
Related in: MedlinePlus