OCULAR RADIOTHERAPY COMPLICATIONS : BILATERAL KERATITIS AND PANOPHTALMIA - A CASE REPORT

Radiotherapy is the standard treatment for many intraocular and head-neck area cancers, however there are frequent acute complications after external beam radiotherapy, from transient eyelid erythema and dry eye syndrome to complete loss of vision. This case study aims to highlight the different ocular manifestations and especially corneal complications associated with radiotherapy  as well as the therapeutic procedures of a corneal perforation.

Keywords:radiotherapy, radiation-induced keratitis, corneal complications, dry eye syndrome

On clinical examination, we had found reduced vision in the right eye: light perception, limited extraocular motion, with eyelid edema, meibomian gland dysfunction, severe inflammation, BUT<5seconds and Schirmer test<10mm as the severe eye dryness. In addition of conjunctival hyperemia and circumciliary congestion.  On the cornea there was a deep purulent, circumscribed infiltrate with inferior perforation and iris prolapse. Corneal sensitivity was abolished. The C+ Scan revealed an heterogeneous vitreous and cellulitis. On the day of the patient's admission, the left eye was intact with a clear cornea, while the control on the 5th day showed a corneal ulcer in this eye. 

The urgency of the treatment is dictated by the necessity of limiting ocular morbidities: we started topical and systemic antibiotics therapy, after microbiological analysis for cultures, in addition to lubrificating agents and Vitamin A. The patient underwent corneal gluing with lens contact for the left eye which had a rehabilitation after 3 weeks with a good visual outcome. The right eye responded to medical treatment, corneal surgery (conjunctival flaps and keratoplasty)was at high risk of failure  because of dry ocular surface with reduced sensation. 

The radiation dose received is correlated to the onset of eye complications: a significantly higher incidence of corneal injuries is found when Dmax is higher than 40 Gy. Dry eye syndrome is related to lacrimal gland dose. On the other hand, keratopathies are not usually secondary to direct damage, but a consequence of the severe dryness of the eye. Neurotrophic keratitis are secondary to irradiation of the first branch of the trigeminal in the cavernous sinus. Typical delayed effects include cataracts, glaucoma, and retinopathy.

The ocular morbidity incidence of corneal perforations is important, so prompt diagnosis and treatment are critical. Radiation protection is necessary for appropriate treatment programs to minimize complications.