Corneal melting secondary to malnutrition and systemic steroid abuse: a case report

Abstract

Steroids are arguably one of the most important drugs in modern medicine, utilized in many disorders. Their use, however, is not without complications. Medically unsupervised misuse of corticosteroids can have devastating, potentially fatal complications.

We report a case of a 27-year-old female with history of bariatric surgery and extensive weight loss 10 years prior to her presentation at Kasr Al Ainy, Cairo University Hospitals, Emergency Department (ED). She decided, without seeking medical advice, to take 90 mg oral prednisolone to gain weight 3 months before presenting with left corneal melting and perforation. Emergency tectonic graft surgery was done to salvage globe.

Introduction

Corneal integrity consists of an interplay between various factors [1]. A disturbance of this delicate balance leads to its disruption with potentially blinding consequences. Various vitamins and co-factors play an important part in corneal epithelial health, especially vitamin A with increasing reports of deficiency compromising corneal health following bariatric surgery due to malabsorption [2]. We report a case of a 27-year-old female with history of bariatric surgery 10 years ago and systemic steroid abuse 3 months prior to presentation with corneal melt.

Malabsorption and vitamin A deficiency are known to cause dryness and weaken epithelial junctions; however, an inciting factor is needed to initiate the stromal complications. Corticosteroids are known pro-collagenases and weaken corneal immunity as well, predisposing it to various infections potentially leading to corneal melting [3, 4].

Case presentation

A 27-year-old female came to Kasr Al Ainy, Cairo University Hospitals, Emergency Department (ED) complaining of painful diminution of vision along with eye redness starting one month ago. Condition is gradually progressive, and she did not seek prior medical advice.

She has a history of gastric bypass surgery done 10 years ago for management of obesity, following which she lost significant amount of weight, pre-surgery weight being 145 kg and current weight being 52 kg. 3 months ago, she decided to start oral prednisolone 90 mg per day without medical supervision to assist in weight gain following excessive weight loss. 2 weeks prior to her presentation at Kasr Al Ainy ED, she tapered steroids acutely to 7.5 mg per day (Fig. 1).

Fig. 1.

Graphical representation of timeline

On examination, the patient seemed pale, excessively thin and ill-appearing with cushingoid facies (Fig. 2). Orthostatic hypotension was present, and multiple bruises were observed over extremities. Mucous membranes were dry. Ocular examination revealed left corneal perforation with infected, irregular margins (Fig. 3). Anterior chamber (AC) was lost, and ciliary injection was present. Unaided visual acuity was hand motion (HM). Right eye had significant dryness, but examination was otherwise unremarkable. Laboratory investigations revealed hyperkalemia, hypernatremia, anemia - hemoglobin 10.1 g/dL, bleeding tendency - international normalized ratio (INR) 1.6 and hypoglycemia - random blood sugar (RBS) 61.

Fig. 2.

Cushingoid facies, with pale complexion and dry lips

Fig. 3.

Corneal perforation with loss of AC

The patient was diagnosed with adrenal insufficiency, along with marked nutritional deficiency. She was stabilized in the ED and given stress dose steroids (hydrocortisone sodium succinate 100 mg IV) following which emergency tectonic graft surgery was performed along with AC reformation (Fig. 4). She was treated afterwards for steroid-withdrawal induced adrenal insufficiency along with nutritional rehabilitation with internal medicine and endocrinology specialists.

Fig. 4.

Post-OP: tectonic graft

Ultrasound performed after wound stabilization revealed clear vitreous and attached retina. She is currently awaiting perforating keratoplasty (PKP) after full stabilization of medical condition.

Discussion

Corneal melt has a wide list of etiologies and is frequently the result of many insults combined [5]. The process almost always starts with an unhealthy ocular surface, with abnormal tear amount and/or quality, epithelial junction weakness, followed by the rapidly developing cascade of stromal melting. Our case highlights the interplay of multiple risk factors which eventually led to this devastating outcome.

Bariatric surgery is an increasingly popular modality for treatment of obesity. It is currently offered in Egypt for patients with body mass index > 40 kg/m² or > 35 kg/m² with obesity-related conditions [6]. Gastric bypass surgery predisposes patients to fat-soluble vitamin malabsorption due to anatomical changes induced by surgery [7]. Studies have shown that most patients are not compliant with supplement intake following bariatric surgery [8]. Vitamin A is a fat-soluble vitamin which is essential for normal differentiation of non-squamous epithelium, with keratinization resulting from its deficiency [9]. Xerophthalmia has been increasingly reported over the past few years due to increased numbers of bariatric surgery, with many reports of corneal melting and perforation [10]. While our patient had a 10-year history of bariatric surgery and malabsorption (as evidenced by high INR secondary to vitamin K deficiency), we do not believe it to be the sole cause of corneal complication. Dryness and ocular surface disease secondary to vitamin A malabsorption was only the initial event.

Corticosteroids, invaluable drugs in almost every medical subspecialty, have multiple ocular side effects [3]. They are notoriously known for inducing cataract and elevating intraocular pressure but also play a detrimental role in regulating ocular immune response. As useful as this could be (e.g. preventing and treating corneal transplant rejection), lowering ocular immunity predisposes the cornea to various infections as the frequently encountered herpes keratitis reactivation [11]. We believe this to be the second event leading up to the corneal melt. The patient complained of one month of redness, discomfort and diminution of vision which is consistent with reactivation of viral keratitis. Due to lowered immunity, as well as aforementioned ocular surface abnormalities, secondary bacterial infection occurred, leading up to the acute pain and rapid progression to perforation. Topical steroids have been implicated in corneal melting [4]however, to our knowledge this is the first case reporting such a complication from systemic steroids.

Another potential cause of corneal melt in this patient is Addisonian crisis due to abrupt cessation/massive reduction of dose without gradual taper. Corneal ulcers, keratoconjunctivitis and limbal stem cell deficiency have all been reported in conjunction with adrenocortical insufficiency [12–14].

Corneal perforation should be treated promptly to avoid further ocular damage, including cataract formation, glaucoma and endophthalmitis [15]. Management should include treatment of the underlying process leading to stromal melting as well as maintaining structural integrity of the globe, the latter achieved surgically. Options include amniotic membrane grafts (AMG), conjunctival flaps, tissue adhesives, patch grafts and keratoplasty [16]. Smaller perforations could be managed with AMG, tissue adhesives and contact lens [17]. We chose a tectonic graft as perforation was large and central. Emergency corneal transplants are ideal in large central perforations, however, there are some considerations in low-income countries, including cost of procedure, limited eye banks and scarcity of donors due to cultural beliefs [18]. Clear corneal grafts are thus not offered in an acute setting, especially in eyes with potential infections with possibly high rejection rates [19].

Conclusion

Unsupervised use of corticosteroid can lead to sight- and life-threatening complications. Patient education is crucial post-bariatric surgery to prevent severe complications due to nutritional deficiency and/or self-medication.

Authors’ contributions

Rawan Hosny – Data Collection, manuscript writingMaha Saad – Data Collection, manuscript writing.

Funding

The authors did not receive any funding grant for this research.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Informed consent was obtained from patient. This case report followed the tenets of Declaration of Helsinki. Ethics board deemed the study was exempt from ethics review.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report.

Competing interests

The authors declare no competing interests.