Author: Marco Mazzola (Italy)
Co-authors: Carlo Mazzola, Paolo Milani, Cristian Metrangolo, Federica Romanelli
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.
Setting/Venue
Patient was operated at the Ophthalmology Clinic, San Camillo Hospital, Trento, Italy and then referred to the Retina Service of the Multizone Unit of Ophthalmology of the Autonomous Province of Trento, Trento, Italy.
Methods
Case report. Uneventful 2.4 mm phacoemulsification surgery with single piece acrylic monofocal intraocular lens implantation into the lens capsule was performed under topical anesthesia (lidocaine 2%) by an experienced surgeon in the right eye (RE). Standard dose of 1mg/0,1mL intracameral cefuroxime (Aprokam) was administered into anterior chamber for prophylaxis at the end of the surgery. Full ophthalmic examination (best corrected visual acuity (BCVA) and intraocular pressure (IOP) measurement, slit lamp (SLE) and fundus examination) was performed before and after surgery. Patient was dismissed with standard topical postoperative therapy: 1 mg/ml Diclofenac eye drops 4 times a day + 2mg/ml+5mg/ml Betamethasone+Chloramphenicol eye drops 4 times a day. On postoperative day 1 color fundus picture and swept source optical coherence tomography (SS-OCT) were acquired using Topcon DRI OCT Triton (Topcon Corporation, Tokyo, Japan). On postoperative day 3 spectral-domain OCT, OCT angiography and multicolor images were obtained with Spectralis HRA OCT (Heidelberg Engineering, Heidelberg, Germany).
Results
A 65-year-old lady underwent an uneventful RE phacoemulsification surgery using a standard dose of cefuroxime solution. She had no significant medical or drug history. Preoperative BCVA was 20/100 in the RE and 20/20 in the left eye (LE). SLE showed a corticonuclear cataract RE and mild nuclear sclerosis LE. IOP was 15 in the RE and 14 mmHg in the LE. Axial length was 24.13 mm in the RE and 24.17 mm in the LE. Fundus examination was unremarkable in both eyes. On the first postoperative day, the patient complained about painless visual acuity deterioration in the RE. BCVA was 20/200, IOP was 19 mmHg, anterior segment was clear with no signs of inflammation. Fundus examination showed diffuse macular edema in the absence of cotton wool spots or retinal hemorrhages. SS-OCT image revealed a serous macular detachment with extensive subretinal fluid and intraretinal cystoid macular edema (CME), especially in the outer nuclear layer. On postoperative day 3, BCVA recovered up to 20/20, IOP was 16 mmHg, anterior segment remained quiet. OCT showed fully reabsorption of the macular edema and subretinal fluid, with complete restoration of the physiological macular architecture. OCT angiography did not show any alteration.
Conlusions
Based on the findings, a diagnosis of cefuroxime toxic retinopathy was made. In the literature there are several reports of early serous macular detachment and CME following the use of intracameral injection of cefuroxime sodium in a high dose. Our case illustrates that, in the absence of vascular or inflammatory causes, a standard dose of cefuroxime may still be associated with sporadic cases of toxic retinopathy. The etiology is not fully understood and might be related to transient RPE Na⁺/K⁺ pump dysfunction and/or Müller cells impairment. Cefuroxime toxic retinopathy should be considered in cases of low visual acuity during the early postoperative period after uncomplicated phacoemulsification surgery. In clinical practice, many cases might go undetected since the poor vision on the first day follow-up can be attributed to other factors such as corneal edema and inflammation and the retinopathy usually improves by the 1-week follow-up. Standard topical anti-inflammatory treatment appears to be safe and effective in such cases and allows to achieve an excellent functional result.
Financial Disclosure
Authors have no financial conflicts of interest to disclose.
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