Inadvertent Orbital Mitomycin C Injection as a Cause of Ophthalmoplegia and Orbital Necrosis

Theme: Oculoplastic & reconstructive surgery
What: Oculoplastic & reconstructive surgery
Part of: Oculoplastics II: Cutting edge research in oculoplastics! / Oculoplastie II: Recherche de pointe en oculoplastie!
When: 5/31/2024, 02:00 PM - 03:30 PM
Where: Room | Salle 714 A

Abstract

Purpose: Mitomycin C (MMC) is an alkylating agent with the ability to suppress fibroblast proliferation and activity, making it a powerful antifibrotic. MMC is popular in glaucoma filtering surgeries, both intraoperatively during bleb formation and post-operatively as an adjunct to needling procedures to address episcleral fibrosis and bleb encapsulation. Here we present a rare but serious risk of bleb needling with MMC; inadvertent orbital injection that resulted in inflammation, ptosis, ophthalmoplegia, and orbital necrosis.

Study Design: Case report and literature review.

Methods: We present an illustrative case of orbital necrosis causing ptosis and ophthalmoplegia following inadvertent orbital injection of MMC during a bleb needling. We highlight the investigations and clinical course to inform both glaucoma and oculoplastic specialists about this potential complication. A literature review for orbital sequelae following MMC injection was also performed.

Results: A 66-year-old woman had elevated intraocular pressure despite previous Xen stent and maximum medical therapy. In an attempt improve the performance of her Xen, she underwent a bleb needling at the slit lamp with injection of MMC. During the procedure the patient moved, causing the needle to enter the superonasal orbit with local injection of MMC (40 ng). The following day she awoke with periorbital edema, erythema, and difficulty opening the eye. There was no improvement on Cephalexin for presumed preseptal cellulitis. In oculoplastic consultation three weeks later there was complete ptosis, reduced levator function, marked limitation in ocular ductions, and a palpable mass in the superonasal orbit. A CT scan of the orbits found no abscess or involvement of the orbital apex. During an excisional biopsy of the orbital mass numerous adhesions and fibrotic tissues extended from the mass to the levator muscle. Pathology identified acute and chronic inflammation composed of lymphocytes, plasma cells, and eosinophils with extensive fat necrosis. Special stains were negative for fungal microorganisms and mycobacteria. Pathology, immunostaining, and flow cytometry did not identify any malignancy. When followed over the next year her ptosis slowly but fully resolved and there was improvement in levator function. She has a deep upper eyelid sulcus secondary to the fat atrophy, and scarring of the levator to the superior rectus has caused a persistent supraduction deficit without diplopia in primary gaze.

Conclusions: While there are reports of accidental intraocular injection of MMC, to our knowledge this is the first reported case of inadvertent orbital injection of MMC during a bleb revision. Potential sequelae of MMC to orbital tissues includes inflammation, fat necrosis, ptosis, and ophthalmoplegia. After ruling out infectious, infiltrative, and malignant causes, these orbital sequelae may be safely observed and can improve over time.

Presenter(s)

Presenting Author: Ryan Mason

Additional Author(s):

Kenneth Chang, University of Toronto

David Yan, University of Toronto- Resident Program

Georges Nassrallah, University of Toronto

Dan DeAngelis, University of Toronto

---