May a post‐radiation ocular surface disorder compromise penetrating keratoplasty surgery? A case report

Abstract

Aims/Purpose: Ocular surface disorder after ocular radiation therapy, even commonly reported, remains overlooked. Any delay in diagnosis may lead to vision threatening complications. The presented case highlights the clinical outcome of a severe post‐radiation ocular surface disorder, the importance of intense therapy and the limitations of further surgical interventions.Methods: Case report.Results: A 34‐year‐old woman was referred with complains of painful and reddish right eye since years. Her medical history revealed an iris melanoma excision at the age of 29 years. Due to recurrence, a proton beam treatment has been performed thereafter. Consequently, the patient developed post‐radiation retinopathy with macula edema, secondary glaucoma, cataract, as well as a severe ocular surface disorder with corneal decompensation and band keratopathy. Several surgical treatments have been attempted among which: phacoemulsification with IOL implantation, trabeculectomy with mitomycin C. Due to refractory glaucoma a Baerveldt glaucoma drainage was necessitated, thereafter. Despite these various therapeutic approaches, there was no improvement of the ocular surface problem. With increasing deterioration of the corneal situation, a penetrating keratoplasty, has been discussed.Conclusions: The continuous worsening of clinical symptomatology of the proton beam radiotherapy ocular surface disorder can be the result of a post‐radiation syndrome. An ischaemic retinopathy and anterior segment disorder lead to engorgement of posterior and anterior segment tissues. Gradual expansion of ischemia, vasculitis and inflammatory mediators compresses the retinal tissue leading to recurrent macular oedema; as well as to secondary glaucoma and corneal decompensation. Due to the worsening of the clinical presentation of ocular surface disorder a penetrated keratoplastic surgery has been discussed. It remains however still questionable whether such patients would make profit from penetrated keratoplastic surgery, as the resulting corneal stromal lymphangiogenesis and hemangiogenesis, in the presence of post‐radiation keratopathy, are essential conditions for allograft rejection.