Acute Attack of Glaucoma after Scleral Melting and Iris Blockage of the Surgical Ostium: A Case Report of a Complication Derived from a Mitomycin C Supplemented Trabeculectomy

Aim

To describe a case of an acute attack of glaucoma due to scleral melting in the area where a trabeculectomy was previously done. This condition resulted from the blockage of the surgical opening due to an iris prolapse in an eye that was previously supplemented with mitomycin C (MMC) during a filtering surgery and bleb needling revision.

Case description

A 74-year-old Mexican female with a prior glaucoma diagnosis who assisted to an appointment presenting an acute ocular hypertensive crisis after several months of adequately controlled intraocular pressure (IOP). Ocular hypertension had been regulated after undergoing a trabeculectomy and bleb needling revision; both supplemented with MMC. The severe IOP increase occurred due to uveal tissue blockage in the filtering site, related to melting of the sclera in the same area. The patient was successfully treated through the use of a scleral patch graft and the implantation of an Ahmed valve.

Conclusion

An acute attack of glaucoma associated with scleromalacia after trabeculectomy and needling has not been previously reported and is currently attributed to MMC supplementation. Nevertheless, the use of a scleral patch graft and further glaucoma surgery seems to be an efficient way to treat this condition.

Clinical significance

Even though this complication was appropriately managed with this patient, we want to prevent further cases like this through the judicious and careful use of MMC.

How to cite this article

Paczka JA, Ponce-Horta AM, Tornero-Jimenez A. Acute Attack of Glaucoma after Scleral Melting and Iris Blockage of the Surgical Ostium: A Case Report of a Complication derived from a Mitomycin C Supplemented Trabeculectomy. J Curr Glaucoma Pract 2022;16(3):199-204.

Serratia marcescens endophthalmitis after pterygium surgery: a case report

Background

To report a case of Serratia marcescens endophthalmitis after pterygium surgery using the bare sclera technique with mitomycin C (MMC).

Case presentation

A 69-year-old male patient underwent pterygium excision surgery using the bare sclera technique and 0.02% MMC. The patient presented with decreased visual acuity and pain from the day after the operation. Trans pars plana vitrectomy was performed and intravitreal antibiotics were administered. Cultures from the aqueous humor and intraocular lens were all positive for S. marcescens, which was sensitive to an empiric antibiotic regimen. The best corrected distant visual acuity, 1 month after treatment, was a finger count/50 cm, but the retinal layer structure and the vasculature were relatively well preserved.

Conclusions

This is the first reported case of S. marcescens endophthalmitis after pterygium surgery. Endophthalmitis caused by S. marcescens has a devastating visual prognosis and may show a high clinical risk-benefit ratio for the application of MMC in pterygium surgery.

Tailored treatment for the management of scleral necrosis following pterygium excision

The present study aimed to investigate the efficacy of tailored treatment for the management of scleral necrosis following pterygium surgery. A series of nine cases of scleral necrosis following pterygium excision between September 2009 and September 2012 were included. In cases where ischemia was the cause of scleral necrosis, Tenon's membrane covering (TMC) surgery was performed. For cases with surgically-induced necrotizing scleritis (SINS), systemic immunosuppressive therapy following surgical repair of the scleral defect was administered in the form of oral prednisolone (starting dose, 30–60 mg/day). Five patients with ischemic scleral necrosis received TMC postoperatively. Four patients with SINS received various doses of oral prednisolone according to their systematic immune state. All patients had successful postoperative results except one with rheumatoid arthritis, who postoperatively developed scleral patch graft melting within 2 weeks. Following aggressive immunosuppressive treatment, the scleral patch graft was saved. In conclusion, patients achieved positive results using tailored treatment according to the pathogenesis of their scleral necrosis.

Mitomycin C-associated scleral stromalysis after pterygium surgery

PURPOSE

To describe complications after use of mitomycin C (MMC) as a surgical adjuvant in pterygium surgery.

METHODS

This is a retrospective chart review of patients presenting to a tertiary referral center over a 7-year period with a diagnosis of scleral stromalysis after previous pterygium removal.

RESULTS

Sixteen eyes of 15 patients were identified with scleral stromalysis after pterygium surgery with the use of adjuvant MMC. Three eyes were excluded because of insufficient chart information or previous beta-irradiation treatment. Twelve of 13 eyes underwent surgical treatment for primary pterygium, and 1 eye was treated for recurrent pterygium. Time from initial pterygium surgery to presentation ranged from 1 month to 10 years. Dosage and routes of MMC administration included 0.02% intraoperative application to either the bare sclera or Tenon capsule with a range of 30 seconds to 3 minutes or topical administration 4 times daily for 2 weeks. In some cases, the dose and route of MMC administration were unknown. Four of 13 patients (31%) required a scleral patch graft with 1 patient (8%) requiring multiple patch grafts.

CONCLUSIONS

Use of MMC in various forms and concentrations can cause devastating complications including scleral stromalysis. Scleral stromalysis may present anywhere from months to years after application. We suggest that MMC should be used with extreme caution when used as a surgical adjuvant for pterygium surgery. Patients must be urged to continue long-term follow-up after MMC use because of the potential for future anterior segment complications.

Management of canine corneal squamous cell carcinoma with lamellar keratectomy and strontium 90 plesiotherapy: 3 cases

PURPOSE

To report three cases of canine corneal squamous cell carcinoma (SCC) treated with strontium 90 beta radiation as an adjunct to surgical excision.

METHODS

Corneal SCC was excised with lamellar keratectomy. This was followed by local application of strontium 90 beta radiation.

RESULTS

Available case follow-up times range from 3 to 50 months. One case suffered a recurrence 5 months following initial excision and strontium 90 treatment.

CONCLUSION AND DISCUSSION

Strontium 90 beta radiation has been used extensively as an adjunctive treatment for equine corneal SCC and in other canine ocular tumors; however, there is a paucity of information regarding use in canine corneal SCC. The cases presented here suggest its use following keratectomy may be helpful in preventing disease recurrence. At the dosage used, severe adverse effects were not observed.

Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection

PURPOSE

To evaluate the complications of cosmetic wide conjunctivectomy and postoperative topical mitomycin C application with or without bevacizumab injection.

DESIGN

Cross-sectional cohort study.

METHODS

Medical records of 1713 consecutive subjects who received cosmetic wide conjunctivectomy plus postoperative topical mitomycin C by a single surgeon at a single center with or without bevacizumab injection from November 2007 to May 2010 were reviewed. A telephone interview was conducted with 557 of the subjects who could be contacted and agreed to participate in the study. Complications, recurrences, and patient satisfaction were the main outcome measures.

RESULTS

A total of 1713 consecutive patients underwent cosmetic wide conjunctivectomy to treat conjunctival hyperemia. Ocular diagnoses in the medical records at the time of surgery included hyperemia (8.8%), pterygium (14.0%), dry eye (3.5%), pinguecula (1.5%), and conjunctival disorder (23.3%). For the remaining 48.9% of subjects, the diagnosis was not mentioned, or the surgical procedure was for cosmetic purposes. Patients were followed for a mean of 10.9 months (range, 0-30.3 months). The overall complication rate was 82.9%, of which 55.6% were considered severe (fibrovascular conjunctival tissue proliferation, 43.8%; scleral thinning, 4.4%; scleral thinning with calcified plaques, 6.2%; intraocular pressure elevation, 13.1%; diplopia, 3.6%; and recurrence of hyperemic conjunctiva, 28.1%).

CONCLUSIONS

Cosmetic wide conjunctivectomy plus postoperative topical mitomycin C with or without bevacizumab injection has a high rate of complications and reoperations.

The development of scleromalacia after regional conjunctivectomy with the postoperative application of mitomycin C as an adjuvant therapy

A 40-year-old woman presented with ocular discomfort in both eyes that had persisted for several months. Six months ago, she had undergone a bilateral nasal and temporal conjunctivectomy using a bare scleral technique followed by a postoperative application of 0.02% mitomycin C (MMC) to treat her chronic hyperemic conjunctiva for cosmesis. Slit-lamp examination revealed that the patient had bilateral nasal and temporal scleral thinning, and a calcified plaque on her nasal conjunctiva. There was no episcleral tissue present around the wound area, and it was difficult to detect any normal conjunctival tissue in the adjacent area for covering the lesion. We believe that performing an aggressive conjunctival excision procedure followed with MMC application for cosmetic enhancement may be disastrous in certain cases.

[Limbal-conjunctival autograft in pterygium surgery]

INTRODUCTION

The aim of this study was to estimate the efficacy of limbal-conjunctival autograft in the treatment of pterygium.

MATERIAL AND METHODS

We conducted a retrospective study including 15 patients (16 eyes) operated on for pterygium by limbal-conjunctival autograft. The examination included the search for risk factors and visual acuity, as well as corneal astigmatism and pterygium measurement. The follow-up included an examination at day 8, 1 month, and 3 months and assessed the integration of the transplant on the eye's surface, the aesthetic aspect, and recurrence. We describe the patients' characteristics, visual acuity, and astigmatism before and after surgery.

RESULTS

The mean age of the patients was 56 years (range, 31-81 years). Before surgery, irritative signs and astigmatism, were found in 37% and impaired visual acuity in 81%. The mean duration of the follow-up after surgery was 19 months. Visual acuity and astigmatism improved in 56% of our patients. All transplants and harvest sites had a satisfactory macroscopic aspect. However, one patient suffered from a corneal invasion by fibrovascular tissue, 7 months postoperatively, which remained stable at the end of follow-up.

DISCUSSION/CONCLUSION

In our study, the limbal-conjunctival autograft was a safe and effective surgical treatment with a very low recurrence rate at long-term follow-up.

Simple excision alone versus simple excision plus mitomycin C in the treatment of pterygium

BACKGROUND

Pterygium is a common ocular disorder throughout the world. The purpose of this study was to evaluate the efficacy of simple excision alone with or without topical mitomycin in the treatment of pterygium.

PATIENTS AND METHODS

This study was performed in two stages. In the first stage, from 1991 to 1994, 100 patients (group 1) were operated on with simple excision and in the second stage, from 1995 to 1999, 300 patients (group 2) were treated with the same procedure plus topical mitomycin (0.02% eye drops four times a day for 4 days after operation). All cases were followed for 5 years. The recurrence rate of pterygium in these two treated groups were compared.

RESULTS

The mean age of the subjects was 49+/-13 years in group 1 and 47+/-17 years in group 2. The clinical manifestations in these two groups were similar (P>0.05). After one year, relapse was seen in 21 cases (21%) in group 1 and in 3 cases (1%) in group 2. After five years, 31 cases (31%) in group 1 and 3 cases (1%) in group 2 had relapse (P=0.0001). The mean time to recurrence at five years for the simple excision group was 3.83 years (95% CI: 3.48 to 4.17 years) and for simple excision plus mitomycin C was 4.96 years (95% CI: 4.91 to 5.0 years) (P<0.0001).

CONCLUSION

Instillation of mitomycin C eye drops appears to be safe in the treatment of pterygium.

Combined "symmetrical conjunctival flap transposition" and intraoperative low-dose mitomycin C in the treatment of primary pterygium

PURPOSE

To introduce a new technique of conjunctival reconstruction after primary pterygium excision, and to evaluate the efficacy of combined "symmetrical conjunctival flap transposition" and intraoperative low-dose mitomycin C application in preventing recurrence of primary pterygium.

METHODS

In a prospective, non-comparative case series, 43 eyes of 41 consecutive patients with primary pterygium were studied. In all patient eyes, after excision of pterygia, 0.02% mitomycin C was applied topically for 2 min over the exposed scleral surface and "symmetrical conjunctival flap transposition" was performed to reconstruct the conjunctival defect. The main outcome measures were pterygium recurrence or any complications related with surgery or mitomycin C.

RESULTS

The mean age of the patients was 47.5 +/- 12.4 years (range 30-70 years). Among the 38 patients who were not lost to follow up, three patient eyes (7.5%) had grade 1, 24 eyes (60.0%) had grade 2 and 13 eyes (32.5%) had grade 3 pterygium. The mean follow up was 12.2 +/- 5.7 months (range 7-28 months). No recurrence or sight-threatening complications were encountered in any patient eye throughout the follow-up period.

CONCLUSION

Combined "symmetrical conjunctival flap transposition" and intraoperative low-dose mitomycin C application may be an effective surgical alternative in preventing recurrence of primary pterygium. Although the procedure seems to be free from severe complications, surgeons and patients should be well aware of the risk of late radiomimetic complications of mitomycin C. Comparative, randomized trials with more number of patients and longer follow up are required to further establish the safety and efficacy of this treatment strategy.

Corneal Keratocyte Apoptosis Following Topical Intraoperative Mitomycin C in Rabbits

PURPOSE

To determine the soaking duration and concentration effect of mitomycin C (MMC) on the corneal keratocyte following single intraoperative application.

METHODS

Two hundred ten pigmented rabbit eyes underwent mechanical epithelium debridement of the central 10-mm comea followed by soaking of six different solutions: MMC1A: 0.01% MMC x 1 minute; MMC1B: 0.01% MMC x 2 minutes; MMC2A: 0.02% MMC x 1 minute; MMC2B: 0.02% MMC x 2 minutes; BSS1: balanced salt solution (BSS) x 1 minute; and BSS2: BSS x 2 minutes. Thirty-five eyes were allocated into each group. Changes of the central comeal thickness, corneal clarity score, and keratocyte apoptosis were examined on days 0, 1, 2, 3, 5, 7, and 14.

RESULTS

A significant increase of central corneal thickness and corneal clarity score was noted in all MMC treated groups. The central corneal thickness recovered to its baseline level whereas the corneal clarity score remained increased at 2 weeks. The changes were more significant in MMC2 than in MMC1 corneas. However, changes of central corneal thickness and corneal clarity score were more significant in MMC1B than in MMC1A, whereas no difference was noted between MMC2A and MMC2B. Significantly higher stromal keratocyte loss and keratocyte apoptosis, from superficial to deep corneal stroma, was noted in MMC1 and MMC2 groups up to 14 days postoperatively, in a soaking duration and dose-dependent manner.

CONCLUSIONS

Single application of MMC on the corneal surface caused soaking concentration and duration dependent corneal edema and keratocyte apoptosis in this rabbit model.

Comparison of Amniotic Membrane Graft Alone or Combined With Intraoperative Mitomycin C to Prevent Recurrence After Excision of Recurrent Pterygia

PURPOSE

Without effective adjunctive therapy, the recurrence rate after excision of recurrent pterygia is high. In an effort to determine a way to better reduce the recurrence of pterygia, we compared the efficacy and safety of amniotic membrane graft (AMG) alone and AMG combined with intraoperative mitomycin C after excision of recurrent pterygia.

METHODS

Patients with recurrent pterygia were randomly assigned to receive excision of pterygia followed by AMG alone or AMG combined with intraoperative 0.025% mitomycin C for 3 minutes (AMG-mitomycin C). Patients who could be followed up for more than 12 months were entered for data analysis. Conjunctival (potential) and corneal (true) recurrence of pterygia and other complications were recorded.

RESULTS

The group receiving AMG alone was made up of 48 eyes in 48 patients, and the group receiving AMG-mitomycin C consisted of 47 eyes in 46 patients. No significant difference was found in age distribution, sex distribution, or duration of follow-up between the 2 groups. Regarding the recurrence rates of each group, 6 conjunctival (12.5%) and 6 corneal (12.5%) recurrences developed in the AMG group, and 4 conjunctival (8.5%) and 6 corneal (12.8%) recurrences developed in the AMG-mitomycin C group. No significant difference was found in the conjunctival and corneal recurrence rate between the 2 groups (P=0.623 and 0.966, respectively; log rank test), and no major complications developed in either group.

CONCLUSIONS

AMG alone can be considered an effective alternative adjunctive treatment of recurrent pterygia. The addition of intraoperative mitomycin C did not further reduce the recurrence rate.

Long-term effects of mitomycin C in pterygium surgery on scleral thickness and the conjunctival epithelium

PURPOSE

To evaluate the long-term effects of intraoperative application of mitomycin C on the scleral thickness and the conjunctival epithelium at the surgical site of pterygium excision.

DESIGN

Prospective observational case series.

PARTICIPANTS

Twenty-four patients who underwent excision of primary pterygium with intraoperative mitomycin C in our department during the year 1996.

METHODS

Patients were evaluated by slit-lamp biomicroscopy, impression cytology, and high-frequency ultrasonography. Impression cytology was performed by applying a small nitrocellulose filter paper for a few seconds at the excision area and for a few seconds at the opposite perilimbal area, and subjecting the specimens to the periodic acid-Schiff-Gill modified Papanicolaou staining protocol. The morphology of the conjunctival epithelium and goblet cell density (GCD) were recorded. High-frequency ultrasound was performed at the same sites, and the scleral thickness was measured at a distance of 1 mm from the limbus.

MAIN OUTCOME MEASURES

Goblet cell density, conjunctival epithelial morphology, and the scleral thickness at the operated and nonoperated sites.

RESULTS

All patients had successful pterygium removal with no corneal recurrence after a mean follow-up of 77.2+/-3.9 months (range, 72-84). Impression cytology revealed normal nongoblet conjunctival epithelial cells at the excision area, with a 4-fold decrease in the GCD at the excision area when compared with the contralateral nonoperated site (296+/-120 cells/mm(2) and 1183+/-310 cells/mm(2), respectively; P = 0.0036). No differences were noted between the scleral thicknesses at the operated site (750+/-70 microm) and the opposite site (740+/-80 microm) (P = 0.84).

CONCLUSIONS

A single application of mitomycin C after pterygium excision is not associated with reduction in scleral thickness more than 6 years postoperatively. The conjunctival epithelium retains its normal phenotype, with a marked reduction of the GCD.