Extensive autoimmune keratolysis with subsequent corneal perforation managed with tectonic endothelial keratoplasty

PURPOSE: To report a case of corneal perforation secondary to an extensive rheumatologic corneal melt, that was successfully managed via systemic immunosuppression and internal tectonic endothelial keratoplasty (TEK). OBSERVATIONS: A 55-year-old male with undiagnosed rheumatoid arthritis presented with a progressively enlarging area of peripheral ulcerative keratitis with extensive keratolysis which subsequently perforated despite treatment with oral steroids. The structural integrity of the globe was restored via a combination of cyanoacrylate glue and tectonic endothelial keratoplasty (TEK). This technique provided long term structural support and improved visual acuity. CONCLUSIONS AND IMPORTANCE: TEK grafts represent a viable treatment option in a subset of patients with corneal perforation secondary to an extensive corneal melt. The familiarity and relative ease of the surgical technique along with a lack of corneal sutures represents an alternate technique when compared to full thickness or lamellar keratoplasty. Further, through the use of anterior segment spectral domain optical coherence tomography (SD-OCT) we demonstrate that the donor graft integrated within the host cornea. To our knowledge, this represents the first case in the literature of corneal perforation secondary to an inflammatory corneal melt that was successfully managed with internal tectonic endothelial keratoplasty.