Older man presents with spontaneous corneal perforation

A 76-year-old man presented urgently to the New England Eye Center with decreased vision in the left eye after experiencing a “gush of fluid from the eye.” The symptoms were spontaneous in onset, without history of ocular trauma or mechanical insult. He reported no acute pain but did report continuing burning, irritation and mild foreign body sensation related to chronic dry eye syndrome. He had a history of myelodysplastic syndrome and previously had a bone marrow transplantation.At time of presentation, the patient’s best corrected visual acuity was 20/200 in the left eye. There was no afferent pupillary defect. Extraocular motility was normal. IOP measurement was deferred due to corneal findings. Conjunctival superficial punctate keratopathy was noted, alongside diffuse injection and subepithelial fibrosis on lid eversion. The cornea was hazy in appearance and contained a 4.5 mm × 0.5 mm horizontal linear epithelial defect noted in the inferior portion of the central visual axis, originating nasally. The defect extended to variable depth throughout its length, full thickness in depth at the temporal most edge. There was a region of stromal thinning to the level of Descemet’s membrane temporally. The anterior chamber was shallow and contained fibrin strands. There was no cell, flare, hypopyon or hyphema.