##article.abstract##
The subject is a male patient with a history of rheumatoid arthritis, dry eye syndrome and corneal transplant 3 years ago. Patient reports decreased visual acuity in his right eye. On physical examination, a rejection line is detected in meridian 6 of the cornea and temporal conjunctival hyperemia. A month later, he reports increased pain, conjunctival hyperemia, excessive secretion and visual acuity decreased to finger count at 3 meters in his right eye. The examination reveals a 360º corneal vascularization and aseptic perforation of the central cornea. The first therapeutic measure was cyanoacrylate and soft contact lenses, moxifloxacin 0.5% eye drops every 4 hours and sodium hyaluronate 0.1% eye drops. Fifteen days later, he did not report improvement and his visual acuity was reduced to finger count at 2 meters. On examination, neovascularization in four quadrant and seidel test was positive. The next day a conjunctival graft was performed improving the clinical condition; finally, a second tectonic corneal transplant was executed. The therapeutic and surgical approach to a corneal perforation depends on the size, shape, location and cause of the lesion, with cyanoacrylate tissue adhesives being useful in small lesions.##submission.citations##
Kemeny-Beke A, Szodoray P. Ocular manifestations of rheumatic diseases. Int Ophthalmol. 2020;40(2): 503-510. Available from: https://doi.org/10.1007/s10792-019-01183-9
Generali E, Cantarini L, Selmi C. Ocular Involvement in Systemic Autoimmune Diseases. Clinic Rev Allerg Immunol. 2015;49(3): 263-270. Available from: https://doi.org/10.1007/s12016-015-8518-3
Kumar V, Kumar A. Immunological aspects of corneal transplant. Immunological Investigations. 2014; 43(8): 888-901. Available from: https://doi.org/10.3109/08820139.2014.910024
Di Zazzo A, Kheirkha A. Management of high risk corneal transplantation. Survey of Ophthalmology. 2017; 62 (6):816-827. Available from: https://doi.org/10.1016/j.survophthal.2016.12.010
Lemp M. Dry eye (Keratoconjunctivitis Sicca), rheumatoid arthritis, and Sjögren’s syndrome. Am J Ophthalmol. 2005; 140(5): 898–899. Available from: https://doi.org/10.1016/j.ajo.2005.06.031
Villani E, Galimberti D, Viola F, Mapelli C, Del Papa N, Ratiglia R. Corneal involvement in rheumatoid arthritis: an in vivo confocal study. Invest Ophthalmol Vis Sci. 2008;49(2): 560–564. Available from: https://doi.org/10.1167/iovs.07-0893
Kobayashi A, Yokogawa H, Sugiyama K. Management of a small paracentral corneal perforation using iatrogenic iris incarceration and tissue adhesive. Case Rep Ophthalmol. 2012;3(2): 226-229. Available from: https://doi.org/10.1159/000341094
Yokogawa H, Kobayashi A, Yamazaki N, Masaki T, Sugiyama K. Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital. Clin Ophthalmol. 2014;8: 2165-2170. Available from: https://doi.org/10.2147/OPTH.S71102
Hanada K, Igarashi S, Muramatsu O, Yoshida A. Therapeutic keratoplasty for corneal perforation clinical results and complications. Cornea. 2008; 27(2): 156-160. Available from: https://doi.org/10.1097/ICO.0b013e31815b82f2
Rashmi D, Louis JS, Rasik V. Management of corneal perforations: An update. Indian J Ophthalmol. 2020;68(1): 7-14. Available from: https://doi.org/10.4103/ijo.IJO_1151_19
