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 .