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

Rama Rajagopal; Swetha Ravichandran; Janarthanam Jothi Balaji

doi:10.4103/ijo.IJO_1907_22

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

Rama Rajagopal¹, Swetha Ravichandran¹, Janarthanam Jothi Balaji²
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 Submission	05-Aug-2022
Date of Acceptance	28-Sep-2022
Date of Web Publication	20-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

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1907_22

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 Jun 9];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

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

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

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.

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