Mitomycin
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Sclerocorneal necrosis, fungal scleral keratitis and endophthalmitis: case report A 46-year-old woman developed sclerocorneal necrosis, fungal scleral keratitis and endophthalmitis during treatment with mitomycin for pterygium surgery. The woman underwent a nasal pterygium excision in her left eye. During surgery, she received topical 0.02% mitomycin [mitomycin C], which was soaked in a sponge and placed on the bare sclera for 60 seconds with subsequent irrigation. Her postoperative course was uncomplicated. However, on the 14th post-operative day, she developed redness in her left eye, with ocular pain. On post-operative day 21, she presented for follow-up and showed visual acuity of light perception. A slit lamp exam showed scleral necrosis with nasal thinning around the area of pterygium excision. Her central cornea was clear with nasal thinning in an area. The adjacent sclera and limbus were found to be relatively avascular. Additionally, inflammation of the anterior chamber with hypopyon and vitritis were noted. The woman was admitted and scheduled to undergo a pars plana vitrectomy and a scleral patch graft, with intravitreal antibiotic treatment. She was treated with gatifloxacin, vancomycin, moxifloxacin and prednisolone. Her vitreous cultures returned positive for coagulase-negative staphylococcus species. After 4 days of the vitrectomy, her cornea showed diffuse infiltrate with an overlying central epithelial defect; the scleral patch graft was intact. Her anterior chamber remained significantly inflamed. Within 7 days of the vitrectomy, she showed minimum improvement. She underwent corneal scraping for isolation of the organism. Initially, yeast was identified and she was treated with systemic fluconazole. At that time, her cornea had become completely opaque. An ultrasound examination (B scan) was consistent with diffuse infiltrates. Subsequent cultures were positive for fusarium species infection and she was initiated on nystatin drops. Her fluconazole was switched to voriconazole and prednisolone was weaned off. On post-operative day 10, her condition had deteriorated further and she was referred to a tertiary care centre. A slit lamp exam showed severe conjunctival injection and corneal melting. Her cornea had completely infiltrated and appeared opaque with uveal prolapse. She underwent placement of a big tectonic graft over her entire cornea to prevent perforation. A biopsy of the excised cornea confirmed the presence of fusarium species. Her visual acuity deteriorated to no light perception within 2 days of presentation to the tertiary care centre. Her hypopyon grew and filled the anterior chamber. An B scan revealed funnel shaped retinal detachment with dense vitreous debris. Her eye was enucleated to prevent fungemia on post-operative day 13. Pathological findings showed areas of marked necrosis with disorganisation of the sclera and adjacent cornea. The development of scleral necrosis was attributed to treatment with mitomycin, which in turn increased susceptibility of opportunistic infecti
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