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What Is a Melting Ulcer (Corneal Melt)?

A melting ulcer, also called corneal melt, is a rapidly progressive corneal ulcer in which enzymes break down stromal collagen. The cornea becomes soft, thin, and at high risk of perforation. Causes include severe infection, autoimmune disease, and sterile inflammatory reactions at the corneal margin. Patients often have significant pain, redness, and decreased vision. Because tissue loss can occur over hours to days, this condition is treated as an emergency.

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What Is a Melting Ulcer (Corneal Melt)?

A melting ulcer, also called corneal melt, is a rapidly progressive corneal ulcer in which enzymes break down stromal collagen. The cornea becomes soft, thin, and at high risk of perforation. Causes include severe infection, autoimmune disease, and sterile inflammatory reactions at the corneal margin. Patients often have significant pain, redness, and decreased vision. Because tissue loss can occur over hours to days, this condition is treated as an emergency.

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Causes and Pathophysiology of Corneal Melt

Corneal melt is driven by an imbalance between collagen destructive enzymes and protective inhibitors in the corneal stroma. Matrix metalloproteinases and other proteases are released by neutrophils, keratocytes, and sometimes pathogens. Autoimmune disorders such as rheumatoid arthritis and granulomatosis with polyangiitis can trigger peripheral ulcerative keratitis that melts the cornea. Severe bacterial, fungal, or herpetic infections can also lead to enzymatic destruction. Topical medications and ocular surface disease sometimes contribute to the process.

Clinical Features and Examination

Patients present with intense pain, photophobia, tearing, and reduced vision. On slit lamp exam, there is an epithelial defect over an area of stromal thinning with gray white necrotic tissue. The cornea can look soft and may show Descemet membrane folds or local bulging when very thin. Anterior chamber reaction and hypopyon are common in infectious cases. Peripheral melts can be associated with adjacent scleral inflammation and conjunctival injection.

Diagnosis and Workup

Diagnosis is based on the appearance of a rapidly thinning corneal ulcer with signs of stromal liquefaction. Corneal scrapings are taken for Gram stain, culture, and sometimes fungal and viral studies when infection is suspected. Laboratory tests for autoimmune disease are ordered for peripheral or bilateral melts, including markers for rheumatoid arthritis and vasculitis. Imaging of adjacent sclera and orbit is considered when deep inflammation is present. Prompt identification of systemic disease is important for management.

Treatment and Prognosis

Treatment is urgent and usually combines intensive topical therapy with systemic medication. Broad spectrum topical antibiotics are started for possible infection and are adjusted once culture results return. Systemic corticosteroids and immunosuppressive agents are used for autoimmune related melts after infection is controlled. Collagenase inhibitors such as oral doxycycline and topical agents help reduce enzymatic activity. Tissue adhesives, amniotic membrane, lamellar grafts, or full thickness keratoplasty may be required to restore corneal integrity. Prognosis depends on how quickly the process is halted and on the underlying cause.

FAQs About Melting Ulcers

Can a melting ulcer heal without a transplant?

Some melts can stabilize with medical treatment and limited tissue support such as glue or amniotic membrane, but deep or large defects often need graft surgery.

Are melting ulcers always caused by infection?

No. Many are sterile and related to autoimmune disease or severe surface inflammation. That is why cultures and systemic workup are important.

How fast can a corneal melt progress?

In some cases, significant thinning develops over one to two days, which is why urgent evaluation and frequent follow up are needed.

Will vision return to normal after a melting ulcer?

Vision depends on scar location, graft clarity, and control of the underlying disease. Central melts often leave some permanent visual reduction.

References

EyeWiki (American Academy of Ophthalmology). ?Peripheral Ulcerative Keratitis.? https://eyewiki.org/Peripheral_Ulcerative_Keratitis

NCBI Bookshelf (StatPearls). ?Peripheral Ulcerative Keratitis.? https://www.ncbi.nlm.nih.gov/books/NBK574556/

NCBI Bookshelf (StatPearls). ?Corneal Ulcer.? https://www.ncbi.nlm.nih.gov/books/NBK539689/

American Academy of Ophthalmology (AAO) EyeNet. ?Corneal Perforations.? https://www.aao.org/eyenet/article/corneal-perforations

EyeWiki (American Academy of Ophthalmology). ?Management of Descemetocele and Corneal Perforation.? https://eyewiki.org/Management_of_Descemetocele_and_Corneal_Perforation