Author: Jae Ku (United Kingdom)
Co-authors: Joanne Wong, Laura Steeples, Claire Delaney, Cecilia Fenerty
Purpose
To present a case of severe retinal toxicity secondary to high dose cefuroxime administered during trabeculectomy glaucoma surgery. We describe the clinical features and management and describe serial multimodal imaging and electroretinogram (ERG) findings. To the best of our knowledge, this is the first report of cefuroxime retinal toxicity in trabeculectomy surgery, instead of cataract surgery, which is of particular significance because of the possible differences in pharmacokinetics within the eye.
Setting/Venue
Cefuroxime is routinely administered during intra-ocular surgery to prevent post-operative endophthalmitis, with intra-cameral injection widely adopted in cataract surgery. Toxicity to both intra-cameral cefuroxime (ICC) and sub-conjunctival cefuroxime (SCC) during cataract surgery has been reported.
Methods
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/0.1mls 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 (BCVA) was hand movements, and he had pigment cells in the AC and dull macular reflex. Uveitis was observed with vitreous cells and haze. Optical coherence tomography (OCT) demonstrated serous macular detachment (SMD), characteristic schisis-like changes in the outer nuclear layer (ONL) and ellipsoid zone (EZ) disruption. He was managed with intensive topical steroid and non-steroidal therapy, subconjunctival dexamethasone (3.3mg/ml) and orbital floor depomedrone (40mg/1ml).
Results
Serial OCT, fundus autofluorescence and OCT-angiography images and ERG findings are presented in conjunction with clinical findings during 3-months follow-up. Initial full-field ERG showed decreased a-wave and b-wave amplitude, which normalised within 6 weeks while his multi-focal ERG showed reduced signals in all rings and gradual improvements at 6-weeks and 3 months. The OCT SMD and ONL schisis-like changes resolved after 5 days and EZ disruption resolved after 9 days. BCVA improved to near pre-operative levels (pre-op VA -0.06 logMAR, last follow-up 0.04 logMAR).
Conlusions
There have been reports of cefuroxime toxicity with standard (1mg/0.1ml) and high dose ICC (2-100mg) and SCC (31.25mg). As ICC and SCC are routinely used in intra-ocular surgery, 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. We highlight the risks of high dose intra-cameral injection, including uveitis and retinal toxicity, and the utility of serial OCT and full-field and multi-focal ERG in this condition. We report a favourable outcome with significant and rapid improvement in retinal structure and function observed during follow-up.
Financial Disclosure
No financial disclosures
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