Role of Topical Insulin in Severe Ocular Graft-Versus-Host Disease With Acute Bilateral Perforation

Graft-versus-host disease (GVHD) hinders the prognosis of patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Ocular GVHD (oGVHD) presents as dry eye syndrome (DES) and may progress to corneal perforation. We report a case of acute bilateral corneal perforation in a 42-year-old male with chronic GVHD. The patient presented with mild pain in his right eye (OD [oculus dexter]) and was diagnosed with corneal perforation. Cyanoacrylate glue and amniotic membrane were acutely applied in OD. However, despite appropriate medical treatment, he later developed a refractory, painless central ulcer. During follow-up, the patient also experienced an unexpected, asymptomatic, acute perforation in the left eye. Due to progressive deterioration of the OD ulcer, topical insulin was initiated, resulting in rapid re-epithelialization and control of oGVHD. This is the second known report of topical insulin therapy in ocular GVHD and the first to document rapid epithelial healing following bilateral spontaneous corneal perforation. It highlights how oGVHD may result in corneal perforation despite adequate treatment and the role of topical insulin in promoting epithelial healing and stabilizing the ocular surface.