A corneal ring ulcer
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A 52-year-old woman was referred by her retina doctors for cornea ulceration and pain 8 days after intravitreal ranibizumab injection for diabetic macular edema. She had been treated with erythromycin ointment, topical moxifloxacin, and therapeutic soft contact lens, which she tolerated for less than 24 hours prior to referral.

On initial presentation to our clinic, the left eye visual acuity was count fingers. Slit-lamp examination is depicted in. Corneal smears and cultures, including those to identify atypical pathogens, were obtained. Confocal microscopy showed only possible double-walled cysts in two images from one sequence. The patient was started on fortified vancomycin and tobramycin, topical chlorhexidine and oral valacyclovir. Cultures and smears were all negative. Fortified antibiotics were discontinued after 2 weeks, and ofloxacin 0.3% 4x/day and polymyxin/bacitracin ointment nightly were substituted. Slit lamp examination three weeks after the treatment initiation. Repeat smears and cultures at 3 and 5 weeks were negative, as was confocal microscopy.

At 6 weeks, acanthamoeba keratitis was excluded and chlorhexidine was discontinued. The ring infiltrate had not changed in size and appearance. At this point, a presumptive diagnosis of neurotrophic ulcer was made. Ofloxacin, polymyxin/bacitracin ointment and lid taping were continued and topical loteprednol 0.5% twice daily was added. An in-office trial of a therapeutic soft contact lens with brand and parameters different from what was previously tried was again intolerable to the patient.

Ten days later, the epithelial defect healed with modest symptomatic relief, but a 3 × 4mm recurrence was noted at examination 9 days later.

The patient was then treated with topical cenegermin, 6x daily, which was well tolerated and led to symptom reduction, decreased central ring density/opacity and closing of the epithelial defect. One week after an 8-week course of cenegermin, vision was 20/400, the epithelium remained intact, and ring and stromal opacities were reduced. The epithelium remained intact at subsequent examinations, the most recent occurring 16 weeks after cessation of cenegermin therapy.