Corneal perforation secondary to medial canthal fistula in cocaine-induced midline destructive lesions

To report a rare case of corneal perforation precipitated by an abnormally positioned globe, lagophthalmos and exposure keratopathy secondary to medial canthal fistula in cocaine induced midline destructive lesions (CIMDL). We describe the clinical presentation of a middle-aged man who developed a corneal perforation secondary to medial canthal fistula and enophthalmos and adduction caused by CIMDL. He underwent combined strabismus surgery, cornea patch grafting and tarsorrhaphy, but ultimately required evisceration. Thereafter, his medial canthal fistula was closed with a double layered skin flap. Destructive medial canthal and orbital vasculitis can compromise the protection of the ocular surface and result in corneal perforation. Subsequent management of residual medial canthal fistulas can be challenging and risks failure in the future, especially if there is ongoing aggressive tissue destruction.