systemic chemotherapy can lead to a variety of ocular complications , such as cicatricial ectropion , nasolacrimal duct stenosis , conjunctivitis , keratitis , cataract , macular edema , retinopathy , and optic neuropathy ( 1 , 2 ) .
although bulbar perforation with orbital cellulitis has been reported in an immunocompromised patient , corneal perforation has not been documented in patients undergoing systemic chemotherapy ( 3 ) .
we report a case of corneal perforation with preseptal cellulitis in a patient treated with systemic chemotherapy for acute lymphocytic leukemia ( all ) .
a 17-yr - old female patient undergoing systemic chemotherapy for all was referred to our hospital due to swelling and pain of the right upper lid for two days .
laboratory examination showed leukocytes 40 cells/l , erythrocytes 3.610 cells/l , hemoglobin 10.8 g / dl , hematocrit 30.6% , and thrombocytes 3310 cells/l .
the patients received induction chemotherapy ( vincristine , prednisolone , daunorubicin , and l - asparaginase ) .
there were no abnormal findings , other than diffuse swelling of the right upper eyelid .
artificial tear eye drops were used for the treatment of superficial punctate erosions . on the 12th day
, spontaneous bloody and purulent discharge from the upper palpebral conjunctiva occurred in the right eye .
systemic antibiotics ( meropenem ) were maintained per the antibiotic sensitivity test . on the 16th day ,
periorbital swelling decreased , however , corneal melting and perforation with iris prolapse was noted in the right eye ( fig .
seven months after surgery , visual acuity in the right eye was 20/300 , and intraocular pressure was 14 mmhg .
ocular complications associated with systemic chemotherapy can be divided into complications in the adnexa , anterior segment , and posterior segment .
previously reported complications in the anterior segment include conjunctival injection , conjunctivitis , corneal edema , keratitis , and corneal opacity ( 1 , 2 ) .
anticancer agents such as cytosine arabinoside , 5-flurouracil , carmustine , deoxycoformycin , and tamoxifen have been known to cause corneal toxicity ( 1 , 2 , 4 , 5 ) . in our case ,
vincristine , prednisolone , daunorubicin , and l - asparaginase were used for combination chemotherapy . to the best of our knowledge , corneal toxicity associated with these anticancer agents has not been reported .
serratia marcescens , a motile , gram - negative coccobacillus , is an emerging opportunistic pathogen noted for causing urinary , respiratory , blood stream , and ocular infections ( 6 ) .
preseptal cellulitis in the present case was caused by s. marcescens because the patient was immunocompromised .
extracellular protease produced by s. marcescens is considered a major corneal destructive factor . in an experimental study of rabbit cornea ,
serratia protease preparations have caused rapid and extensive liquefactive corneal necrosis , descemetocele formation , and corneal perforation ( 7 ) .
it is possible that s. marcescens in the purulent discharge directly invaded the cornea with superficial punctate erosions and caused corneal melting and perforation in the immunocompromised patient .
this hypothesis is supported by two facts : first , s. marcescens is a virulent organism .
second , corneal melting and perforation occurred in the area in direct contact with the infected upper palpebral conjunctiva . in conclusion
, physicians should consider the possibility of serious ocular complications , such as severe bacterial keratitis or corneal perforation in cases of preseptal cellulitis caused by a virulent organism , particularly in immunocompromised patients .
 we report a case of corneal perforation with preseptal cellulitis in a patient with acute lymphocytic leukemia ( all ) . a 17-yr - old female patient who was undergoing combination chemotherapy for all 
 was referred due to upper lid swelling and pain in the right eye for 2 days . 
 visual acuity in the right eye was 20/20 . 
 initial examination showed no abnormal findings , other than swelling of the right upper eyelid . computed tomography showed a finding of preseptal cellulitis . 
 microbiologic study of bloody and purulent discharge revealed serratia marcescens . 
 corneal melting and perforation with iris prolapse were detected in the right eye on the 16th day . 
 emergent tectonic keratoplasty was performed . 
 seven months after surgery , visual acuity in the right eye was 20/300 , and the corneal graft was stable . 