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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 55-57

Presumed viral endotheliitis following topical mitomycin C for the treatment of ocular surface squamous neoplasia in a glaucoma patient


1 Department of Cornea and Refractive Surgery, Medical Research Foundation, Chennai, Tamil Nadu, India
2 Optometry Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission05-Aug-2022
Date of Acceptance28-Sep-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Rama Rajagopal
Department of Cornea and Refractive Surgery, Sankara Nethralaya, Medical Research Foundation, 41, College Road, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1907_22

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  Abstract 


Corneal endotheliitis and ocular surface neoplasia are known to be associated with altered immune status especially in the elderly. We reviewed an interesting case where endotheliitis occurred for the first time while on topical chemotherapy for ocular surface neoplasia in a patient with glaucoma. We have addressed the practical concerns in decision-making given multiple ocular comorbidities and highlighted a successful outcome with no recurrence of both the tumor and the endotheliitis for over 16 months.

Keywords: Chemoreduction, glaucoma, OSSN, viral endotheliitis


How to cite this article:
Rajagopal R, Ravichandran S, Balaji JJ. Presumed viral endotheliitis following topical mitomycin C for the treatment of ocular surface squamous neoplasia in a glaucoma patient. Indian J Ophthalmol Case Rep 2023;3:55-7

How to cite this URL:
Rajagopal R, Ravichandran S, Balaji JJ. Presumed viral endotheliitis following topical mitomycin C for the treatment of ocular surface squamous neoplasia in a glaucoma patient. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 7];3:55-7. Available from: https://www.ijoreports.in/text.asp?2023/3/1/55/368190



Corneal endotheliitis is rare and may sometimes be associated with a compromised immune status.[1] The etiology is multifactorial, though most commonly viral.[2] We report a case of a 77-year-old glaucoma patient presenting with clinical features suggestive of viral endotheliitis while on treatment with mitomycin C (MMC) for ocular surface squamous neoplasia (OSSN), both treated successfully with no recurrence. We are unaware of any case in literature that presented similarly and highlight the practical considerations in diagnosis when multiple comorbidities coexist and a structured approach to a successful outcome.


  Case Report Top


A 77-year-old gentleman presented with a temporal bulbar conjunctival growth in the right eye for one month. He had undergone an extracapsular cataract extraction (ECCE) along with trabeculectomy with MMC five years ago in that eye followed by Ahmed glaucoma valve (AGV) implant one year ago and was off antiglaucoma medications (AGM) since then. Slit-lamp examination revealed an 11 × 6.5 mm, corneo-conjunctival papillomatous lesion from 7 to 11 o'clock with feeder vessels suggestive of OSSN [Figure 1]a. Rose Bengal stain was positive. BCVA was 20/32 and 20/20 in the right and left eye, respectively. AGV tube was in place, and disc showed advanced glaucomatous changes with intraocular pressures (IOPs) of 18 mmHg in both eyes. Gonioscopy revealed open angles. Anterior segment optical coherence tomography (ASOCT) showed hyperreflective and thickened epithelium with abrupt transition between normal and abnormal tissue and back shadowing suggestive of OSSN [Figure 1]b. Serology for human immunodeficiency virus was negative. He had not received COVID vaccination. Chemotherapy options with topical interferon alpha 2 B (INF α2b)/MMC was discussed. The patient opted for MMC and was prescribed a one-week-on-and-one-week-off cycle of 0.04% MMC following catgut occlusion. After two cycles, there was a 50% reduction in the size and no surface toxicity. He was advised two more cycles. However, two days prior to completion of the second cycle, the patient presented with sudden onset decrease in vision, photophobia, mild circumciliary congestion, stromal edema, Descemet membrane folds with small-to-medium pigmented keratic precipitates suggestive of viral endotheliitis. ASOCT confirmed the clinical findings and presence of keratic precipitates [Figure 1]c and [Figure 1]d. OSSN had resolved completely both clinically and on ASOCT. The patient was treated with topical prednisolone acetate 1% ophthalmic suspension (PRED FORTE®) six times a day tapered weekly and oral valacyclovir hydrochloride (VALTREX®) 500 mg two times a day for seven days and thereafter on a maintenance dose for six months. Endotheliitis resolved completely over three months and vision improved to 20/60. At a follow-up of 16 months, the patient had a quiet eye with mild corneal haze, no recurrence of OSSN or endotheliitis [Figure 2]a and [Figure 2]b.
Figure 1: (a) Clinical photograph showing OSSN extending 4 o'clock hours from 7 to 11 o'clock position in the right eye at presentation. (b) ASOCT depicting hyperreflective and thickened epithelium at presentation. (c) Clinical photograph showing corneal edema with Descemet membrane folds during fourth cycle of MMC (d) corneal edema and keratic precipitates on ASOCT suggestive of viral endotheliitis

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Figure 2: (a) Clinical photograph. (b) AS-CT depicting minimal corneal haze and no recurrence of OSSN or viral endotheliitis at 16 months follow-up

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  Discussion Top


OSSN and endotheliitis can both occur in old age due to compromised immune status.[3],[4] We herein discuss practical issues in the diagnosis and management in these eyes.

OSSN in a glaucoma patient

Diagnosis of OSSN in a glaucoma patient can be challenging as conjunctival or corneal toxicity due to anti-glaucoma medications can mask an early diagnosis of OSSN.[5] Careful bleb evaluation is essential to ascertain bleb involvement though conjunctival scarring in a failed bleb could possibly limit the circumferential spread like in our case and that in a study by Yadav et al.[6]

INF α2b versus MMC in chemoreduction

INF α2b may be preferred over MMC despite prolonged time of resolution in these eyes, as it is less toxic resulting in lesser conjunctival inflammation and scarring and this helps to preserve conjunctiva for a future glaucoma surgery.

Corneal edema in a glaucoma patient

Several factors could have resulted in endothelial compromise although it is not clinically evident. Besides age, multiple surgeries can result in endothelial loss. Secondly, Benzalkonium Chloride (BAK) can lead to conjunctival squamous metaplasia and anterior chamber inflammation.[7],[8] Thirdly, both reduction in endothelial cell density (ECD) and endothelial cell count has been reported following MMC use in photorefractive keratectomy (PRK).[9],[10] However, in PRK, the duration of exposure to MMC is much less and following epithelial removal.

OSSN and viral endotheliitis

Corneal endotheliitis is characterized by corneal edema, keratic precipitates, anterior chamber inflammation, and coexisting or superimposed uveitis. It is most often caused by HSV or CMV and can be distinguished based on the type of edema and clinical distribution of keratic precipitates.[2] Anterior chamber (AC) tap can confirm the etiology but rarely carries possible risk of endophthalmitis, wound leak, and sympathetic ophthalmia and is preferably considered in vision threatening[2] or a typical presentations. High index of clinical suspicion is necessary as early endotheliitis can be missed for MMC toxicity. Considering the recent history of OSSN and classical clinical presentation of viral endotheliitis complemented by ASOCT findings, we deferred AC tap. In eyes when there is coexisting or recently treated OSSN, there is also a potential risk of intraocular seeding following AC tap.

In our case, we suspect that elderly age, previous intraocular surgeries, use of AGM with preservatives for long duration prior to surgery, and MMC use could have compromised both the surface and the endothelium, despite it not being clinically evident, evident—resulting in the eye being susceptible to endotheliitis, although the possibility of coincidental occurrence cannot be ruled out.


  Conclusion Top


Our case highlights that some of these eyes, especially those of elderly patients, are susceptible to multiple comorbidities. High index of clinical suspicion can aid in early diagnosis and a tailored approach can result in successful outcomes. Despite the rarity of occurrence, we recommend the use of INF α2b for chemoreduction for OSSN especially in elderly patients with a compromised surface. Besides chemoreduction and less toxicity, its possible role as an antiviral agent may help to minimise viral reactivation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suzuki T, Ohashi Y. Corneal endotheliitis. Semin Ophthalmol 2008;23:235-40.  Back to cited text no. 1
    
2.
Moshirfar M, Murri MS, Shah TJ, Skanchy DF, Tuckfield JQ, Ronquillo YC, et al. A review of corneal endotheliitis and endotheliopathy: Differential diagnosis, evaluation, and treatment. Ophthalmol Ther 2019;8:195-213.  Back to cited text no. 2
    
3.
Meel R, Dhiman R, Vanathi M, Pushker N, Tandon R, Devi S. Clinicodemographic profile and treatment outcome in patients of ocular surface squamous neoplasia. Indian J Ophthalmol 2017;65:936-41.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Wang H, Zheng J, Zheng Q, Yang F, Ye C, Woo DM, et al. Incidence and risk factors of new onset endotheliitis after cataract surgery. Invest Ophthalmol Vis Sci 2018;59:5210-6.  Back to cited text no. 4
    
5.
Nakagawa S, Usui T, Yokoo S, Omichi S, Kimakura M, Mori Y, et al. Toxicity evaluation of antiglaucoma drugs using stratified human cultivated corneal epithelial sheets. Invest Ophthalmol Vis Sci 2012;53:5154-60.  Back to cited text no. 5
    
6.
Yadav SP, Patil SS, Deshpande RD. Management of ocular surface squamous neoplasia extending up to a filtering trabeculectomy bleb. Indian J Ophthalmol 2020;68:2540-2.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Asbell PA, Potapova N. Effects of topical antiglaucoma medications on the ocular surface. Ocul Surf 2005;3:27-40.  Back to cited text no. 7
    
8.
Stevens AM, Kestelyn PA, De Bacquer D, Kestelyn PG. Benzalkonium chloride induces anterior chamber inflammation in previously untreated patients with ocular hypertension as measured by flare meter: A randomized clinical trial. Acta Ophthalmol 2012;90:e221-4.  Back to cited text no. 8
    
9.
Moshirfar M, West WB Jr, Milner DC, McCabe SE, Ronquillo YC, Hoopes PC. Delayed epithelial healing with corneal edema and haze after photorefractive keratectomy using intraoperative mitomycin C. Int Med Case Rep J 2021;14:863-70.  Back to cited text no. 9
    
10.
Morales AJ, Zadok D, Mora-Retana R, Martínez-Gama E, Robledo NE, Chayet AS. Intraoperative mitomycin and corneal endothelium after photorefractive keratectomy. Am J Ophthalmol 2006;142:400-4.  Back to cited text no. 10
    


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