Publications

Ocular nonsteroidal anti-inflammatory drugs (NSAIDs) and corneal melting

Published: 1 June 2023
Prescriber Update 44(2): 32–33
June 2023

Key messages

Corneal melting is a serious ophthalmological condition that can lead to corneal perforation and vision loss.
Use of ocular nonsteroidal anti-inflammatory drugs has been associated with serious corneal adverse events, including signs/symptoms suggestive of corneal melting.
Patients with signs/symptoms suggestive of corneal melting should discontinue treatment and seek immediate medical advice.

Ocular nonsteroidal anti-inflammatory drugs (NSAIDs) are prescription medicines used for the prophylaxis and treatment of ocular inflammation and/or pain associated with ocular conditions, often in the post-operative setting.¹ This article is a reminder that serious corneal adverse events can occur with these medicines.

What is corneal melting?

Corneal melting is a serious ophthalmological condition that begins with a defect in the corneal epithelium. If the defect is not corrected, the collagen in the corneal stroma breaks down, leading to corneal thinning. In some cases, corneal melting progresses to corneal perforation and vision loss.²

Various conditions can cause corneal melting, including eye infections, sterile inflammation, certain medical conditions (such as rheumatoid arthritis), and surgical or chemical injury to the cornea.³

Use of ocular NSAIDs has recently been linked to corneal melting. However, the mechanism behind this association is unknown.²

NSAID-induced corneal melting

Consider the possibility of corneal melting in patients using ocular NSAIDs who complain of blurred/distorted vision, worsening eye pain, eye irritation and hypersensitivity and/or ocular discharge. Check these patients for corneal damage.^4,5

Risk factors

Certain situations may increase the risk for NSAID-induced corneal melting, including (list not exhaustive):

frequent application and/or prolonged treatment duration⁴
concomitant use of corticosteroids⁴
concomitant conditions such as acute eye infections, rheumatoid arthritis, diabetes mellitus, ocular surface disease^4–6
recent complicated ocular surgery or patients with repeat ocular surgeries within a short period of time.^4,5

Associated corneal disorders

Corneal disorders associated with corneal melting have been reported with ocular NSAID use. The Voltaren Ophtha and/or Acular Eye Drops data sheets include information about the following:

punctate keratitis⁴ (damage to the cells on the surface of the cornea)
ulcerative keratitis^4,5(corneal ulcer)
corneal perforation^4,5
corneal thinning^4,5
corneal epithelial defect⁴or breakdown⁵
corneal opacity.⁴

Management

Advise patients to seek urgent medical attention if they experience signs/symptoms suggestive of corneal melting. Early diagnosis and treatment are critical to prevent further corneal damage.⁷

Patients with evidence of corneal epithelial breakdown should immediately discontinue ocular NSAID treatment and be closely monitored.^4,5

Due to the risk of corneal perforation and vision loss, patients with corneal melting are usually managed in a specialist setting. Management of corneal melting may involve medical and/or surgical intervention.⁸

New Zealand information

More than 11,000 people per year are dispensed an ocular NSAID.⁹ Up to 22 March 2023, the Centre for Adverse Reactions Monitoring (CARM) had not received any case reports suggestive of corneal melting with ocular NSAIDs.

See the ocular NSAID data sheets for information about known corneal effects. Search for a data sheet.
As with any medicine, please report suspected adverse events with ocular NSAIDs to CARM.

References

New Zealand Formulary. 2023. NZF v130: Ocular peri-operative drugs 1 April 2023. URL: nzf.org.nz/nzf_6020 (accessed 11 April 2023).
Rigas B, Huang W and Honkanen R. 2020. NSAID-induced corneal melt: Clinical importance, pathogenesis, and risk mitigation. Survey of Ophthalmology 65(1): 1-11. DOI: doi.org/10.1016/j.survophthal.2019.07.001 (accessed 28 March 2023).
Hossain P. 2012. The corneal melting point. Eye (Lond) 26(8): 1029-30. DOI: 10.1038/eye.2012.136 (accessed 28 March 2023).
Novartis New Zealand Limited. 2022. Voltaren Ophtha New Zealand Data Sheet 2 November 2022. URL: medsafe.govt.nz/profs/Datasheet/v/voltarenophtha.pdf (accessed 28 March 2023).
Allergan New Zealand. 2018. Acular Eye Drops New Zealand Data Sheet May 2018. URL: medsafe.govt.nz/profs/datasheet/a/aculareyedrops.pdf (accessed 28 March 2023).
Sule A, Balakrishnan C, Gaitonde S, et al. 2002. Rheumatoid corneal melt. Rheumatology 41(6): 705-06. DOI: 10.1093/rheumatology/41.6.705 (accessed 29 March 2023).
Medsinge A, Gajdosova E, Moore W, et al. 2016. Management of inflammatory corneal melt leading to central perforation in children: a retrospective study and review of literature. Eye (Lond) 30(4): 593-601. DOI: 10.1038/eye.2015.278 (accessed 12 April 2023).
Dana R. 2023. Ocular manifestations of rheumatoid arthritis. In: UpToDate 7 March 2023. URL: uptodate.com/contents/ocular-manifestations-of-rheumatoid-arthritis (accessed 28 March 2023).
Te Whatu Ora. 2022. Pharmaceutical Data Web Tool 7 November 2022. URL: tewhatuora.shinyapps.io/pharmaceutical-data-web-tool/ (accessed 12 April 2023).