MAR 11, 2011
This article reports on six cases of intraocular inflammation that occurred after intracameral injection at the end of uneventful cataract surgery of a very high dose of cefuroxime due to improper dilution and reconstitution of the antibiotic. The day after surgery, all patients had poor vision and ocular inflammation. At six weeks postop, the inflammation resolved and the visual outcome was satisfactory in all cases without surgical intervention. However, the authors say that long-term retinal function must be assessed through repeated electroretinography (ERG) recordings.
These cases represented all of the phacoemulsification cataract surgeries performed on one day by an eye surgeon using cefuroxime for the first time. Due to the surgeon's error, the patients were each injected with 40.0 to 50.0mg of cefuroxime instead of the recommended dose of 1.0 mg.
One day postoperatively, the mean corrected distance visual acuity (CDVA) was 0.95 logMAR ± 0.40 (SD). Retinal optical coherence tomography scans systematically showed extensive macular edema (mean 843.2 ± 212.7 mm) associated with a large serous retinal detachment. Fluorescein angiograms showed diffuse leakage without abnormal retinal perfusion. At five days, the mean CDVA improved significantly to 0.52 ± 0.29 logMAR (P < 0.005), as did the macular edema and serous retinal detachment (mean 339.4 ± 138.3 mm) (P = 0.005). At six weeks, the mean CDVA reached 0.09 ± 0.06 logMAR. Modifications in central corneal thickness and endothelial cell density were similar to those observed after uneventful phacoemulsification. The macular thickness (mean 288.4 ± 22.6 mm) and profile returned to normal in all patients, although ERG recordings showed reduced rod photoreceptor cell function (P < 0.05).
The postoperative anterior chamber inflammation observed in the patients shares some characteristics with toxic anterior segment syndrome (TASS), according to the authors, to whom the patients were referred due to their postoperative problems. As in TASS, the postoperative anterior chamber inflammation in the six patients began within 24 hours after surgery and was associated with fibrin formation. Also there was corneal edema, and it improved with topical steroid treatment. However, unlike TASS, inflammation was not restricted to the anterior segment, which they say argues in favor of a diagnosis of mild toxic endophthalmitis.
They conclude that with the increased use of intracameral cefuroxime at the end of cataract surgery, there is clearly a need for a self-preserved ophthalmic formulation to avoid the risk of dilution error during extemporaneous compounding. However, they say that the short-term stability of cefuroxime after reconstitution remains a limiting factor that must be overcome. In the meantime, the authors say it is the surgeon's duty to avoid dilution errors when using off-label drugs by carefully studying the recommended protocols before use. When extemporaneous preparation is performed in a hospital pharmacy, multidisciplinary cooperation is essential, and control of the medication's labels in advance by the surgeon remains mandatory.