What is the treatment for corneal melt?

Treatment of Corneal Melt

Corneal melt requires immediate discontinuation of any topical NSAIDs, initiation of oral doxycycline or tetracycline-class antibiotics to inhibit matrix metalloproteinases, and consideration of surgical intervention ranging from tissue adhesive to keratoplasty depending on perforation status and size. 1, 2, 3

Immediate Medical Management

Stop Causative Agents

• Discontinue all topical NSAIDs immediately if they are being used, as they are a well-documented cause of corneal melt through epithelial desquamation and stromal collagen degradation via matrix metalloproteinase activation 2, 4, 5
• Evaluate for medication toxicity from other topical agents, which can cause worsening inflammation or corneal melting 1

Anticollagenolytic Therapy

• Initiate oral doxycycline or minocycline to counteract corneal stromal thinning by inhibiting matrix metalloproteinases 1, 3
• Oral tetracycline-class antibiotics stabilize corneal breakdown and prevent progression to perforation through their anticollagenolytic activity independent of antimicrobial effects 3
• Oral N-acetylcysteine can also be used as an adjunctive agent to inhibit matrix metalloproteinases 1

Infection Control

• Apply topical broad-spectrum antibiotics to prevent or treat secondary bacterial infection, which commonly complicates corneal melt 1
• If infectious keratitis is present or suspected, culture the cornea and initiate fortified antibiotics targeting the most likely organisms 1
• Monitor closely for signs of infection (increased suppuration, hypopyon, worsening infiltrate) 1

Surface Stabilization

• Use preservative-free lubricants frequently to maintain epithelial integrity 1
• Consider a bandage contact lens for symptomatic relief and epithelial protection, but only with concurrent prophylactic antibiotics due to infection risk 1
• Apply amniotic membrane transplantation (overlay or inlay technique) to decrease inflammation and stabilize the ocular surface, which can improve prognosis if eventual keratoplasty is needed 1

Surgical Intervention Based on Perforation Status

For Impending Perforation (Extremely Thin Cornea)

• Cyanoacrylate tissue adhesive application with bandage contact lens for small areas of extreme thinning or microperforations 1
• Amniotic membrane transplantation (double-layer preferred) applied 2-5 days after medical therapy initiation can improve visual outcomes and avoid urgent keratoplasty 1
• Consider Tenon's patch graft with cyanoacrylate glue for larger areas of impending perforation 1

For Frank Perforation

• Small perforations (<2mm): Cyanoacrylate tissue adhesive with bandage contact lens 1
• Larger perforations: Tenon's patch graft with cyanoacrylate glue is effective 1
• Tectonic Descemet's stripping endothelial keratoplasty has emerged as an alternative to tectonic penetrating or lamellar keratoplasty for perforation management 1
• Penetrating keratoplasty or lamellar keratoplasty for extensive tissue loss or when other measures fail 1

For Refractory Cases Without Perforation

• Conjunctival flap provides rapid corneal healing, ocular comfort, and reduction in inflammation when visual rehabilitation is not the primary goal 1
• Full Gundersen conjunctival flaps are used as definitive surgery when additional reconstructive surgery is not anticipated 1

Corticosteroid Considerations

When to Avoid

• Do not use topical corticosteroids if infection is present or suspected, as they cause local immunosuppression, inhibit collagen synthesis predisposing to further melting, and can cause recurrence of infection 1
• Corticosteroids should be avoided in Nocardia keratitis, which results in poor visual outcomes 1

When to Consider (Cautiously)

• If infection has been definitively ruled out or controlled, minimal corticosteroid therapy may suppress inflammation and reduce subsequent scarring 1
• Use the minimum amount required to achieve inflammation control with careful dose regulation and close follow-up 1

Adjunctive Measures for Underlying Conditions

• Correct eyelid abnormalities (entropion, ectropion, lagophthalmos) that contribute to corneal exposure and melting 1
• Control intraocular pressure if elevated, avoiding prostaglandin analogues if inflammation is present due to their pro-inflammatory properties 1, 6
• Treat underlying autoimmune disease systemically if present, as conditions like rheumatoid arthritis commonly cause corneal melt 7
• Address ocular surface disease with aggressive lubrication and treatment of dry eye 7

Critical Monitoring Parameters

• Daily follow-up initially for severe cases until stability or clinical improvement is confirmed 1
• Assess for progression of thinning, epithelial defect size, signs of infection, and intraocular pressure 1
• Monitor for complications including perforation, endophthalmitis, and secondary glaucoma 1

Common Pitfalls to Avoid

• Never continue topical NSAIDs once corneal melt is identified, as they directly cause epithelial loss and stromal degradation through matrix metalloproteinase activation 2, 4, 5
• Avoid overtreatment with intentional scarification procedures (anterior stromal puncture), as this can paradoxically lead to necrosis and worsening corneal melt 1
• Do not delay surgical intervention when perforation is imminent or present, as outcomes worsen with progressive tissue loss 1, 7
• Recognize that bandage contact lenses increase infection risk, requiring prophylactic antibiotics and patient education about warning signs (redness, pain, photophobia) 1