Spontaneous corneal melting in pregnancy: a case report
© Arya et al; licensee BioMed Central Ltd. 2007
Received: 29 August 2007
Accepted: 22 November 2007
Published: 22 November 2007
To report a case of spontaneous corneal melting in pregnancy. We reviewed the literature on corneal melting and the effect of pregnancy on cornea and collagen containing tissues.
A 29-year-old woman who underwent radial keratotomy in both eyes followed by trabeculectomy in her left eye developed corneal melting in the same eye, in her seventh month of pregnancy. Despite screening, no infectious or immune mediated condition could be identified. She was managed conservatively with cyanoacrylate glue, bandage contact lens, lubricants and antibiotics.
It may not always be possible to find the underlying cause of corneal melting but the more common underlying causes should be ruled out by proper investigations. Pregnancy with its host of hormonal changes could potentially have some effect on corneal collagen leading to corneal melting in compromised corneas.
A large number of hormonal, metabolic, immunologic, hematologic and cardiovascular changes occur during pregnancy which affects all the tissues including the eye. The effects of pregnancy on the eye are described in three categories. Nonpathological physiological changes like corneal edema with increase in corneal thickness and curvature, decreased corneal sensitivity, increased aqueous outflow facility and changes in visual field. Pathological conditions reported to develop during pregnancy include central serous retinopathy, hypertensive and vascular disorders and uveal melanoma. Pregnancy also affects pre-existing ocular conditions such as diabetic retinopathy, tumors and a variety of immunological disorders and can have beneficial effects on certain pre-existing conditions like glaucoma. We did not find any reported case of spontaneous corneal melting with perforation in pregnancy. We report a case of a pregnant woman who developed spontaneous corneal melting in her 7th month of pregnancy.
Discussion and conclusion
Corneoscleral melting is commonly seen in immune mediated conditions, most common being rheumatoid arthritis. Infections, chemical burns, recti surgery, use of topical steroids, non steroidal anti-inflammatory drugs and non-absorbable sutures[5–7] have been reported as causes of corneal melting and necrotizing scleritis. Rare causes of corneal melting that have been reported in literature are paraneoplastic pemphigus, pyoderma gangrenosum, Vogt-Koyanagi-Harada syndrome and psoriasis. In our case, despite screening; we couldn't find evidence of any of the above.
During pregnancy there are host of hormonal changes, which have different effects on various parts of the body. One of the important hormones produced during pregnancy is relaxin, which is thought to play an important regulatory role in collagen remodeling during gestation. It is a positive regulator of matrix metalloproteinase which has collagenolytic activity. It has differential effect on various collagen containing organs. In various animal models it has been observed that there is a change in the type and content of collagen in pubic symphysis, uterus and cervix , cartilage , and aorta . Striae gravidarum, seen in pregnancy results in tearing of collagen matrix of dermis and weakness of elastic fibers .
It has also been documented that hormonal changes during pregnancy induce corneal edema. Corneal sensitivity has been seen to decrease in pregnant women, with maximum changes in the later half of the pregnancy, which returns to normal by 6 to 8 weeks after delivery. Decline in corneal sensitivity is primarily attributed to corneal edema. On Medline search we found one case report of corneal perforation (not melting) in pregnancy with pre-existing keratoconus. Lahoud et al (1987) reported a case of 24 year old female who had history of bilateral keratoconus and presented with marked corneal edema and perforation in her eighth month of pregnancy and was eventually treated by penetrating keratoplasty .
We hypothesize that relaxin, by virtue of its differential effect, probably acts on corneal collagen as well and may exhibit collagenolytic property. These changes may not be of major concern in a healthy cornea but in compromised corneas they may lead to corneal melting and devastating complications, as seen in our case. Pregnancy as a cause of corneal melting has not been earlier documented, but after extensive investigations and detailed history in our case we could not find any other cause. Further studies are required to evaluate this hypothesis.
The case demonstrates that in high risk females who have compromised corneas, the physiological changes during pregnancy may contribute to development of devastating complications. Hence, such patients should be carefully monitored during pregnancy atleast once in each trimester so that prophylactic treatment can be started at the earliest.
Informed and written consent of the patient was taken for publishing this case report and utilizing the photographs for publication.
The authors had no separate source of funding for this study.
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