An 84-year-old Indian gentleman presented with a 1-month history of right eye pain, redness and photophobia. Four months earlier, he was diagnosed with stage 3 gastric adenocarcinoma (CPS <1; HER2 IHC 2+, FISH negative, pMMR). He had progressive gastric nodal spread despite having completed two cycles of Tegafur/Gimeracil/Oteracil (TS-1) adjuvant chemotherapy regimen 2 months prior. As he was not fit for surgery in view of his risks of receiving general anesthesia, a decision was made for him to receive treatment only with a palliative intent.
His symptoms of right eye redness and ocular discomfort started ~1 month after completing his chemotherapy. On presentation, his best corrected visual acuity (BCVA) was 6/18 in the right eye. Slit lamp examination revealed mild conjunctival injection with two discrete areas of severe peripheral corneal melt spanning two clock hours nasally and two clock hours temporally with 60% thinning. There was an associated overlying epithelial defect, with Descemet membrane folds, and the presence of anterior chamber cells (grade 2). There was no scleritis (Figures 1A,B). Left eye and posterior segmental examination of both eyes were unremarkable. Extensive autoimmune and infective work up, including a full blood count, tuberculosis and syphilis screen, and an autoimmune serum panel (antinuclear antibody, anti-double-stranded DNA antibody, antinuclear antibody profile, ANCA-EIA profile) all returned negative. Due to progressive severe corneal thinning, the patient was then started on IV Methylprednisolone 500 mg/OM for 3 consecutive days, as well as topical steroids of Prednisolone Acetate 1% (Pred Forte, Allergan, Irvine Ca) hourly, Levofloxacin 0.5% (Cravit , Santen, Osaka, Japan) 3 hourly, oral Ciprofloxacin 500 mg twice daily, and oral Doxycycline 100 mg once daily. Over the course of 1 week, there was clinical improvement and thus his treatment was changed to oral Prednisolone 1 mg/kg that was tapered by 10 mg every 3 days. By day 9 of treatment, the area of corneal thinning had epithelized and there was no further stromal melting (Figures 1C,D).