[Serous retinal detachment after phacoemulsification with intracameral cefuroxime (a case-control report)]

Macular Toxicity of Low-Concentration Cefuroxime during Cataract Surgery in Vitrectomized Eyes

INTRODUCTION

The objective of this study was to determine the toxic effect and clinical characteristics of 1 mg/mL cefuroxime sodium on retinas after phacoemulsification in vitrectomized eyes.

METHODS

Cataract patients with vitrectomized eyes were studied retrospectively. Phacoemulsification combined with intraocular lens implantation was performed uneventfully. Best-corrected visual acuity, intraocular pressure, fundus photography, macular central thickness, and angiography were collected and analyzed. They were studied in patients with macular edema to evaluate macular toxicity.

RESULTS

Ninety two cases (92 eyes) were enrolled, including 44 eyes of males and 48 eyes of females with an average age of 55.35 ± 12.32 years. Univariate analysis showed that the intraoperative use of balanced salt solution containing 1 mg/mL cefuroxime sodium compound electrolyte and macular involvement in primary vitrectomy were important risk factors for macular edema on the first day after cataract surgery (p < 0.05). In addition, the characteristics of this kind of macular edema were studied; the thickness of macular fovea was significantly high at 1-day follow-up (p < 0.05), but there was no difference between pre-operation and 1-week post-operation (p > 0.05).

CONCLUSION

Low-concentration cefuroxime sodium can cause acute macular edema in vitrectomized eyes, which can heal within 1 week after surgery.

Acute exudative serous macular detachment with intraretinal oedema following uncomplicated phacoemulsification cataract surgery

We report a case of a white man in his 80s presenting with reduced vision, 1 day following uncomplicated cataract surgery. Optical coherence tomography scan showed evidence of a large collection of subretinal and intraretinal fluid. There was no ocular abnormality of note to explain these macular findings. The findings were presumed to be caused by cefuroxime toxicity despite a standard intraoperative dose of 1 mg/0.1 mL injected into the anterior chamber. We have postulated that the process of discarding excess cefuroxime onto the corneal wound or surface may inadvertently lead to a higher dose entering the eye than intended. This patient was treated with topical prednisolone 1%, ketorolac 0.5% and chloramphenicol 0.5% in place of the standard Maxitrol (dexamethasone 0.1% with neomycin) prescribed as a postoperative regimen in our unit. There was complete resolution of the retinal changes with restoration of normal vision at 3-week follow-up.

High dose cefuroxime causing retinal toxicity in a patient undergoing trabeculectomy

PURPOSE

To present a case of severe retinal toxicity secondary to high dose intracameral cefuroxime administered during trabeculectomy glaucoma surgery. We describe the clinical features and management, and describe serial multimodal imaging and electrophysiological findings. Intracameral cefuroxime (ICC) and subconjunctival cefuroxime (SCC) are routinely administered during ocular surgeries to prevent postoperative endophthalmitis. Cefuroxime toxicity with both standard (1mg/0.1mL) and high doses of ICC (2-100mg) and SCC (31.25mg) have been reported. To the best of our knowledge, this is the first report of cefuroxime retinal toxicity in trabeculectomy surgery, which is of particular significance because of the possible differences in pharmacokinetics within the eye.

OBSERVATIONS

A 69-year-old male with primary open-angle glaucoma, underwent right trabeculectomy, augmented with mitomycin C (0.2mg/mL). The patient inadvertently received cefuroxime 12.5mg/0.1mL as an intracameral rather than a subconjunctival injection. Within 4 hours, the error was discovered and the patient underwent immediate anterior chamber (AC) washout. His right best-corrected visual acuity was hand movements, and he rapidly developed uveitis including AC cells and moderate vitritis and haze. Optical coherence tomography (OCT) demonstrated serous macular detachment, characteristic schisis-like changes in the outer nuclear layer and ellipsoid zone disruption. Multi-focal electroretinograms (ERG) identified deficits undetected by full-field ERG. He was successfully managed with intensive local topical corticosteroid, non-steroidal therapy and peri-ocular corticosteroid injection.

CONCLUSIONS AND IMPORTANCE

As ICC and SCC are routinely used in intra-ocular surgery to prevent endophthalmitis, ophthalmologists need to be aware of this potential complication and consider this in patients with unexplained reduced vision post-operatively. Theatre teams need to be vigilant about potential dilution and administration errors to ensure that the correct concentration and volume of cefuroxime is given via the correct route. We highlight the risks of high dose intracameral injection, including uveitis and retinal toxicity, and the utility of serial OCT, and full-field and multi-focal ERGs in this condition. We report a favourable outcome with significant and rapid improvement in retinal structure and function observed during follow-up. A literature review of the condition is presented.

Acute macular edema and serous detachment on the first day after phacoemulsification surgery: A case report

Purpose

To report a case of an acute macular edema with serous retinal detachment on the first day after uncomplicated phacoemulsification surgery with the use of a standard dose of intracameral cefuroxime at the end of the surgery.

Observations

A 46-year-old man underwent a technically uneventful right eye phacoemulsification surgery using a standard dose (1mg/0.1mL) of cefuroxime solution injected into the anterior chamber at the end of the surgery. Serous macular edema and detachment were in our case observed on the first post-operative day. Without surgical intervention fast clinical recovery was observed and best corrected visual acuity improved to the final visual outcome of 1.0, which was satisfactory 10 days after surgery.

Conclusions and Importance

Acute serous macular detachment and edema should be considered in cases of poor visual acuity in the early postoperative period. The role of a standard dose of cefuroxime toxicity should be more widely explored and discussed.

[Complications of intracameral cefuroxime in cataract surgery]

Intracameral injection of cefuroxime during phacoemulsification is considered effective in preventing endophthalmitis. Its widespread usage has led to the accumulation of data on local and systemic adverse reactions. The analysis of complications of cataract surgery with cefuroxime injections described in literature has allowed identifying a few different clusters of toxic and allergic reactions to intracameral cefuroxime for the first time. These clusters included toxic anterior segment syndrome, serous retinal detachment with macular edema, retinal hemorrhagic infarction and anaphylactic reaction. The first two types develop in the cases of both correct and incorrect dosages, and both have favorable prognosis. Retinal hemorrhagic infarction was observed in cases with more than 50 mg intracameral antibiotic injected in the anterior chamber and was accompanied by persistent irreversible visual deterioration. Anaphylactic shock in response to a standard dose of intracameral cefuroxime was described in patients allergic to penicillin. Every clinical variant has specific complication mechanisms, prevention and treatment options. Antibiotic dilution done by medical staff accounts for the risk of incorrect dosage and related complications. Clinical manifestations of the complications of antibiotic prophylaxis should be considered when specifying the causes of decreased vision in the early postoperative period.