title: Late corneal perforation after photorefractive keratectomy associated with topical diclofenac: involvement of matrix metalloproteinases.
abstract: OBJECTIVE
  To report a case of a 50-year-old man who was initially seen with a corneal perforation in his right eye 2 months after a photorefractive keratectomy (PRK) procedure and to discuss the roles of topical diclofenac and matrix metalloproteinases (MMPs).
  
  
  METHODS
  Case report with tissue analysis.
  
  
  METHODS
  Ocular examination, diagnostic workup, surgical treatment, and histologic, immunofluorescent, zymography, and real time-polymerase chain reaction studies on corneal button.
  
  
  RESULTS
  Slit-lamp examination of the right eye revealed a 4-mm diameter area of central corneal thinning with a 2-mm diameter perforation at its center. Predisposing factors included prolonged postoperative topical diclofenac therapy for more than 2 months and a 10-year history of well-controlled diabetes mellitus. An extensive diagnostic workup ruled out a systemic autoimmune disease. A penetrating keratoplasty was performed. Results of immunohistochemical studies of the corneal button showed stromal accumulation of temporary type III and IV collagens, MMP-3, and MMP-9 in the anterior wounded stroma and MMP-9 in the basal corneal epithelial cells of the leading edge. Differential activity and expression of MMP-2 and MMP-9 were found between the central and peripheral corneal buttons.
  
  
  CONCLUSIONS
  Prolonged use of diclofenac and diabetes mellitus might be responsible for the corneal perforation after PRK in our patient. MMP-9 and MMP-3 might be involved in delayed wound closure and corneal melting.
authors.affiliation: Fondation Ophtalmologique A de Rothschild, Paris, France.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Gabison
authors.forename: Philippe
authors.initials: P
authors.lastname: Chastang
authors.forename: Suzanne
authors.initials: S
authors.lastname: Menashi
authors.forename: Samia
authors.initials: S
authors.lastname: Mourah
authors.forename: Serge
authors.initials: S
authors.lastname: Doan
authors.forename: Michelle
authors.initials: M
authors.lastname: Oster
authors.forename: Alain
authors.initials: A
authors.lastname: Mauviel
authors.forename: Thanh
authors.initials: T
authors.lastname: Hoang-Xuan
mesh_terms: D000287:Administration, Topical; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D024061:Collagen Type III / Q000378:metabolism; D024141:Collagen Type IV / Q000378:metabolism; D003316:Corneal Diseases / Q000139:chemically induced* / Q000201:enzymology* / Q000473:pathology / Q000601:surgery; D003319:Corneal Stroma / Q000187:drug effects / Q000201:enzymology / Q000473:pathology; D004008:Diclofenac / Q000009:adverse effects*; D019084:Fluorescent Antibody Technique, Indirect; D006801:Humans; D015948:Keratoplasty, Penetrating; D054018:Lasers, Excimer; D008297:Male; D020782:Matrix Metalloproteinases / Q000235:genetics / Q000378:metabolism*; D008875:Middle Aged; D018903:Photorefractive Keratectomy; D011183:Postoperative Complications; D012333:RNA, Messenger / Q000378:metabolism; D020133:Reverse Transcriptase Polymerase Chain Reaction
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D024061:Collagen Type III; D024141:Collagen Type IV; D012333:RNA, Messenger; D004008:Diclofenac; D020782:Matrix Metalloproteinases