Influence of Post-radiation Ocular Surface Disorder on Ocular Surgery: A Case Report and Review of the Literature

Abstract

Background Ocular surface disorder after ocular radiation therapy, even though commonly reported, is often overlooked. Any delay in diagnosis may lead to complications that threaten vision. The presented case highlights the clinical outcome of a severe post-radiation disorder of the ocular surface, the importance of intensive therapy, and the limitations of further surgical interventions.

Case presentation A 34-year-old woman was referred for a second opinion due to a years-long history of pain and redness in her right eye (OD) after proton beam therapy for recurrent iris melanoma. The patient then 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, including phacoemulsification with IOL implantation and trabeculectomy with mitomycin C. Due to refractory glaucoma, Baerveldt glaucoma drainage was then necessary. Given the worsening clinical presentation of post-radiation ocular surface disorder with progressing band keratopathy, the possibility of penetrating keratoplasty (PKP) was discussed.

Conclusion The continuous worsening of clinical symptoms of the disorder of the ocular surface after proton beam radiotherapy can be the result of a post-radiation syndrome. Gradual expansion of ischemia, vasculitis, and inflammatory mediators compresses the retinal tissue, leading to recurrent macular edema as well as to secondary glaucoma and corneal decompensation. Band keratopathy is occasionally noted and seems to result from severe post-radiation disorder of the ocular surface. However, PKP would typically be indicated in cases of corneal perforation, uncontrolled infectious keratitis, or for improving vision in the presence of corneal opacification, none of which applied to our patient. Furthermore, post-radiation keratopathy implies compromised corneal stromal lymphogenesis and angiogenesis, both of which are now considered essential conditions for allograft rejection. Moreover, a previously performed Baerveldt glaucoma drainage surgery can affect the survival rate of the endothelial cells of the recipient cornea. Therefore, a penetrating or endothelial keratoplasty should be viewed as a high-risk procedure. In this instance, the rigorous treatment of the severe ocular surface disorder was crucial. We managed our patientʼs complex situation by following the latest guidelines set by the Tear Film & Ocular Surface Society and aimed to alleviate the symptoms as effectively as possible. In conclusion, careful decision-making regarding surgical treatment options should be considered, taking into account the complexities and potential risks involved.

Zusammenfassung

Eine 34-jährige Frau wurde wegen Schmerzen und Rötungen am rechten Auge seit Jahren überwiesen. Ihre Krankengeschichte ergab eine Exzision eines Irismelanoms im Alter von 29 Jahren. Aufgrund eines Rezidivs wurde daraufhin eine Protonenstrahlentherapie durchgeführt. Infolgedessen entwickelte die Patientin nach der Strahlentherapie eine Retinopathie mit Makulaödem, sekundärem Glaukom, Katarakt sowie einer schweren Störung der Augenoberfläche mit Hornhautdekompensation und einer Bandkeratopathie. Es wurden mehrere chirurgische Eingriffe unternommen, darunter die Phakoemulsifikation mit IOL-Implantation und die Trabekulektomie mit Mitomycin C. Aufgrund des refraktären Glaukoms war schließlich auch eine Baerveldt-Implantation erforderlich. Trotz vielfältiger therapeutischer Ansätzen zur Befeuchtung zeigte sich keine Verbesserung des Problems der Augenoberfläche. Aufgrund der Verschlechterung der klinischen Präsentation der Augenoberflächenstörung wurde die Möglichkeit einer perforierenden Keratoplastik in Betracht gezogen. Es bleibt jedoch fraglich, ob solche Patienten von einer perforierenden Keratoplastik profitieren würden, da die resultierende Lymph- und Hämangiogenese des Hornhautstromas wesentliche Risikofaktoren für die Abstoßung von Fremdgewebe darstellen.

Keywords

post-radiation ocular surface disorder - penetrating keratoplasty - lymphogenesis - angiogenesis - endothelial cell loss

Schlüsselwörter

Kornea - okuläre Tumoren - penetrierende Keratoplastik - Lymphogenesis

Publication History

Received: 18 September 2023

Accepted: 03 January 2024

Article published online:
23 April 2024

• References

• 1 Diener-West M, Earle JD, Fine SL. et al. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No. 18. Arch Ophthalmol 2001; 119: 969-982
• 2 Fallico M, Raciti G, Longo A. et al. Current molecular and clinical insights into uveal melanoma (Review). Int J Oncol 2021; 58: 10
• 3 Finger PT. Radiation therapy for orbital tumors: concepts, current use, and ophthalmic radiation side effects. Surv Ophthalmol 2009; 54: 545-568
• 4 Muller K, Nowak PJ, Naus N. et al. Lacrimal gland radiosensitivity in uveal melanoma patients. Int J Radiat Oncol Biol Phys 2009; 74: 497-502
• 5 Paik JS, Cho WK, Lee SE. et al. Ophthalmologic outcomes after chemotherapy and/or radiotherapy in non-conjunctival ocular adnexal MALT lymphoma. Ann Hematol 2012; 91: 1393-1401
• 6 Parsons JT, Bova FJ, Mendenhall WM. et al. Response of the normal eye to high dose radiotherapy. Oncology (Williston Park) 1996; 10: 837-847
• 7 Parsons JT, Bova FJ, Fitzgerald CR. et al. Severe dry-eye syndrome following external beam irradiation. Int J Radiat Oncol Biol Phys 1994; 30: 775-780
• 8 Rosario PW, Calsolari MR. Salivary and lacrimal gland dysfunction after remnant ablation with radioactive iodine in patients with differentiated thyroid carcinoma prepared with recombinant human thyrotropin. Thyroid 2013; 23: 617-619
• 9 Barabino S, Raghavan A, Loeffler J. et al. Radiotherapy-induced ocular surface disease. Cornea 2005; 24: 909-914
• 10 Jones L, Downie LE, Korb D. et al. TFOS DEWS II Management and Therapy Report. Ocul Surf 2017; 15: 575-628
• 11 Zheng Y, Lin H, Ling S. Clinicopathological correlation analysis of (lymph) angiogenesis and corneal graft rejection. Mol Vis 2011; 17: 1694-1700