Neurotrophic corneal melt after deep anterior lamellar keratoplasty

Introduction: This case report features the management of a challenging case of neurotrophic keratopathy (NK). Important considerations in the management of epithelial defects in neurotrophic eyes after corneal transplantation are discussed. Patient and Clinical Findings: A 73-year-old man was referred for management of secondary microbial keratitis on a background of neurotrophic herpes simplex keratitis in the left eye. Acinetobacter parvus was identified and treated. After the resolution of the infection, a residual central corneal scar was significantly affecting vision; therefore, an 8-mm deep anterior lamellar keratoplasty (DALK) was performed 3 years later. Diagnosis, Intervention, and Outcomes: After DALK, a large central epithelial defect occurred, and this progressed to graft melt with a descemetocele. An emergency tectonic DALK was performed along with an amniotic membrane, bandage contact lens, and lateral temporary tarsorrhaphy. No epithelial defect or further melt was observed in the postoperative period, including after removal of the tarsorrhaphy, and at 9 months postoperatively, the graft remains clear with no epithelial defect. Conclusions: In NK, frank epithelial defects, especially after corneal transplantation, require careful consideration. Immediate management options including amniotic membrane transplantation and tarsorrhaphy should be considered to reduce the risk of progression to corneal melting.