A non-healing corneal ulcer as the presenting feature of type 1 diabetes mellitus: a case report
© Ioannidis et al; licensee BioMed Central Ltd. 2011
Received: 10 July 2011
Accepted: 4 November 2011
Published: 4 November 2011
Diabetic keratopathy is a rare complication of diabetes mellitus. This case illustrates the importance of checking blood sugar levels of patients with non-healing corneal ulcers to rule out the possibility of undiagnosed diabetes mellitus.
We report the unusual case of a 24-year-old southeast Asian woman who presented with a sterile corneal ulcer to our hospital and later was found to be diabetic after a prolonged hospital stay. Despite all efforts, the corneal ulcer had failed to heal until treatment for previously undiagnosed diabetes was started. The sterile corneal ulcer began to heal once blood sugar levels began to normalize.
Diabetic keratopathy is a rare complication of diabetes mellitus and needs to be considered as a diagnosis in younger patients with non-healing sterile corneal ulcers. Blood sugar levels should be checked in these cases for undiagnosed diabetes mellitus.
We report an unusual case of a 24-year-old southeast Asian woman who presented with a sterile corneal ulcer to our hospital and later was found to be diabetic. Her corneal ulcer had failed to heal until her blood sugar levels began to normalize. Diabetic keratopathy is a rare complication of diabetes mellitus and needs to be considered as a diagnosis in younger patients with non-healing sterile corneal ulcers. In a previous publication, a 44-year-old man presented in a similar fashion, although in that instance the condition was bilateral . The case in our report highlights the importance of investigating patients who present with unexplained corneal ulceration to exclude undiagnosed diabetes mellitus.
In the third week of admission, she complained of a headache and was found to be mildly tachycardic. She was apyrexial with no reported malaise. A urinary dipstick analysis was performed, and her urinary glucose level was 21 mmol/L. Blood glucose was urgently requested and was found to be 23 mmol/L. A blood gas analysis showed a pH of 7.38, a partial pressure of carbon dioxide (pCO2) of 44.7 mmHg, and a partial pressure of oxygen (pO2) of 89.5 mmHg.
The ocular features of diabetes mellitus have been described in other reports. Impaired glucose metabolism typically results in a localized microangiopathy that affects primarily the retinal vasculature and that produces the classic lesions in the fundus with microaneurysms, intraretinal hemorrhages, exudation, and new vessel formation . A combination of good glycemic control and regular visits to the eye clinic can often slow or halt the progression of the disease.
Diabetic keratopathy is a rare complication of the condition. In this setting, impaired epithelial healing is thought to be a consequence of an abnormal aldose reductase pathway and secondary accumulation of polyol within the epithelial and endothelial cells and thus result in cellular dysfunction [3, 4]. This results in delayed healing responses and loss of epithelial adhesion to the basement membrane, increasing the risk of recurrent corneal erosions. Minor trauma and ocular manipulation with contact lenses can also produce chronic non-healing defects . Our patient had no history of trauma or contact lens use. Other ocular features of diabetes mellitus include reduced corneal sensation and tear production and basement membrane thickening [5–7].
It is important when considering the diagnosis of diabetic keratopathy to exclude other treatable causes of non-healing defects, such as anterior basement membrane dystrophy and recurrent erosion syndrome. Treatment options in cases of a persistent ulceration include the use of frequent lubrication, bandage contact lenses, topical autologous serum drops, and patching. If conservative measures fail, it may be necessary to perform temporary tarsorrhaphy to facilitate healing.
Other conditions that delay epithelial healing need to be identified and treated accordingly. Hence, coexisting neurotrophic keratopathy needs to be excluded by a careful assessment of corneal sensation. Dry eye disease can also delay healing and can be identified with rose-bengal staining of the cornea and conjunctiva and use of the Schirmer test. Nocturnal lagophthalmos needs to be managed with appropriate nocturnal padding and lubrication.
Animal studies have shown that the opioid antagonist naltrexone and insulin used topically can facilitate healing in diabetic rats by enhancing DNA synthesis and re-epithelialization through alterations in local opioid growth factors [8, 9]. In the future, these agents may be approved for use in the treatment of diabetic keratopathy.
Four days after insulin treatment was started, our patient's ulcer had healed and she was discharged from the hospital and follow-up was arranged at her local diabetes clinic. The diagnosis of diabetes mellitus was thus made somewhat incidentally. Our patient did not report weight loss, polyuria, or polydipsia to facilitate the diagnosis of diabetes, and her only complaint was a brief history of headaches while in the hospital. Her urinary glucose level was checked as part of an investigation for transient tachycardia and elevated glucose levels were detected.
Using a combination of a bandage contact lens, temporary punctal plugs, and autologous serum drops proved useful in facilitating ulcer healing. Although the corneal ulcer showed initial signs of healing, it was after the blood sugar levels began to normalize that the ulcer fully healed.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Lockwood A, Hope-Ross M, Chell P: Neurotrophic keratopathy and diabetes mellitus. Eye. 2006, 20: 837-839. 10.1038/sj.eye.6702053.View ArticlePubMedGoogle Scholar
- Ockrim Z, Yorston D: Managing diabetic retinopathy. BMJ. 2010, 341: c5400-10.1136/bmj.c5400.View ArticlePubMedGoogle Scholar
- Akagi Y, Yajima Y, Kador PF, Kuwabara T, Kinoshita JH: Localization of aldose reductase in the human eye. Diabetes. 1984, 33: 562-566. 10.2337/diabetes.33.6.562.View ArticlePubMedGoogle Scholar
- Kinoshita JH, Fukushi S, Kador P, Merola LO: Aldose reductase in diabetic complications of the eye. Metabolism. 1979, 28: 462-469. 10.1016/0026-0495(79)90057-X.View ArticlePubMedGoogle Scholar
- Kaji Y: Prevention of diabetic keratopathy. Br J Ophthalmol. 2005, 89: 254-255. 10.1136/bjo.2004.055541.View ArticlePubMedPubMed CentralGoogle Scholar
- Azar DT, Spurr-Michaud SJ, Tisdale AS, Gipson IK: Decreased penetration of anchoring fibrils into the diabetic stroma. A morphometric analysis. Arch Ophthalmol. 1989, 107: 1520-1523.View ArticlePubMedGoogle Scholar
- Sakamoto A, Sasaki H, Kitagawa K: Successful treatment of diabetic keratopathy with punctal occlusion. Acta Ophthalmol Scand. 2004, 82: 115-117. 10.1111/j.1395-3907.2004.0189h.x.View ArticlePubMedGoogle Scholar
- Klocek MS, Sassani JW, McLaughlin PJ, Zagon IS: Naltrexone and insulin are independently effective but not additive in accelerating corneal epithelial healing in type I diabetic rats. Exp Eye Res. 2009, 89: 686-692. 10.1016/j.exer.2009.06.010.View ArticlePubMedPubMed CentralGoogle Scholar
- Zagon IS, Jenkins JB, Sassani JW, Wylie JD, Ruth TB, Fry JL, Lang CM, McLaughlin PJ: Naltrexone, an opioid antagonist, facilitates reepithelialization of the cornea in diabetic rat. Diabetes. 2002, 51: 3055-3062. 10.2337/diabetes.51.10.3055.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.