A RARE CASE OF CORNEAL PERFORATION FOLLOWING CATARACT SURGERY IN A PATIENT WITH OCULAR ROSACEA: A CALL FOR CAREFUL SURGICAL DECISION-MAKING

To highlight the importance of comprehensive pre-operative assessment and tailored post-operative care, particularly in those with underlying inflammatory conditions like rosacea. This case reminds clinicians to proceed cautiously and ensure rigorous follow-up for patients at higher risk of complications.

Case report

A 75-year-old retired male General Practitioner with a history of ocular rosacea and chronic blepharoconjunctivitis underwent uncomplicated cataract surgery in both eyes—right eye in September 2022 and left eye in October 2022.

Postoperatively, he presented to the acute clinic in November 2022 with a 1-day history of photopsia and right eye pain.

He was diagnosed with corneal melt with perforation at the main cataract incision site in the right eye and signs of corneal melt in the left eye at the main incision site.

Treatment for the right eye included corneal glueing procedures in clinic, pulsed intravenous methylprednisolone 500 mg, oral doxycycline 100 mg once a day per oral, and guttae Levofloxacin 0.5 % four times a day in his right eye. Immune screening was negative.

In January 2023 his corneal was stable, but the patient developed signs of right intermediate uveitis treated with oral prednisolone (tapering regimen over 4 weeks, started with 60 milligrams per day for one week). The vitreous inflammation worsened despite high dose oral steroids and a diagnosis of endophthalmitis was suspected. He underwent aqueous and vitreous sampling and intravitreal antibiotics (Vancomycin 1mg/0.1ml and Ceftazidime 2mg/0.1ml).  Vitreous tap confirmed Staphylococcus spp.

In April 2023, the patient presented with a diagnosed perforation in his right eye that was treated again with corneal gluing.

By September 2023, the corneal glue had dislodged, and a slow leak was detected. He subsequently underwent amniotic membrane transplantation with an inlay into the area of corneal thinning combined with Tisseal ^tm fibrin glue and received a stat dose of intravenous methylprednisolone (500 mg).

Since his last surgical intervention, the patient remains stable and quiescent on regular topical steroid, topical ciclosporin and lubricant.

This case underscores the critical importance of pre-operative ocular surface optimisation in patients with ocular rosacea, as even routine cataract surgery can precipitate severe complications such as corneal perforation and endophthalmitis. 

The case illustrates several key points: (1) the need for careful patient selection in high-risk populations, (2) the role of pre-and post-operative management including aggressive control of ocular surface inflammation, and (3) the importance of early intervention to manage complications, such as corneal glueing or systemic immunomodulation.

This is the first documented corneal perforation at the cataract incision site in a patient with ocular rosacea, highlighting the risks associated with routine cataract surgery in such patients