Accidental Entry of Ointment in Anterior Chamber Postcataract Surgery: A Clinical Conundrum

Abstract

Postoperative complications of cataract surgery are uncommon, and accidental entry of topical ointment into the anterior chamber is a particularly rare event. We report the case of a 67-year-old male with bilateral cataracts and old macular scar in the right eye asteroid hyalosis in the left eye, who developed intraocular migration of 6% sodium chloride ointment following uncomplicated small-incision cataract surgery. On postoperative day 1, a whitish, semi-solid, free-floating material was observed in the anterior chamber, accompanied by mild corneal edema and 1+ anterior chamber cells (SUN classification), initially raising suspicion of early toxic anterior segment syndrome. Due to diagnostic uncertainty, anterior chamber irrigation was performed, during which the material’s consistency confirmed the diagnosis of intraocular ointment entry. This case highlights a rare but important postoperative complication and underscores the need to recognise potential routes of ointment migration, including subtle wound gaping or side-port entry, particularly in patients who may squeeze the eye postoperatively.

INTRODUCTION

With advances in cataract surgery, sutureless techniques have become the standard of care, offering reduced postoperative astigmatism and improved visual outcomes. However, inadequate wound construction or incomplete wound sealing can allow egress of aqueous from the anterior chamber or ingress of external substances into the eye.[1] In small-incision cataract surgery (SICS), both incision size and architecture may contribute to postoperative complications if the tunnel is not fashioned or sealed appropriately. Poorly apposed wounds or inadequate postoperative eye patching may allow squeezing movements that can momentarily open the incision,[2] facilitating unintended fluid entry into the anterior chamber.

Although rare, the entry of ophthalmic ointment into the anterior chamber is a recognized postoperative complication and is most commonly associated with toxic anterior segment syndrome (TASS).[3] TASS is an acute, sterile, inflammatory reaction confined to the anterior segment, occurring after uneventful intraocular surgery. Patients typically present within 12–48 h with decreased vision and ocular discomfort. Clinical signs include limbus-to-limbus corneal edema, anterior chamber cells and flare, fibrinous inflammation, and keratic precipitates. Potentially sight-threatening sequelae include permanent corneal decompensation, refractory glaucoma, and cystoid macular edema.[4] Several published reports describe TASS following accidental intraocular entry of antibiotic steroid ointments during early or delayed postoperative periods.[5]

In this case report, we describe the accidental entry of sodium chloride 6% ointment into the anterior chamber after an otherwise uncomplicated SICS. The ointment, instilled into the lower fornix and bulbar conjunctiva at the end of surgery, likely entered through a poorly sealed scleral incision or through wound gaping induced by postoperative eye squeezing under a loose eye patch. A mobile, whitish, semi-solid deposit was seen in the anterior chamber on postoperative day 1, without the classic features of TASS and without associated symptoms. As the patient had preexisting asteroid hyalosis, calcium deposits migrating into the anterior chamber were also considered. Previous reports have described the spontaneous anterior migration of asteroid bodies through microspaces in intact zonules without posterior capsular rupture.[6] Given these two possibilities, anterior chamber irrigation was performed, and the consistency of the material confirmed the diagnosis of intraocular ointment. This case differs from previous reports as it occurred immediately after an uneventful surgery and presented without typical signs of TASS, highlighting the role of wound integrity and postoperative eye squeezing.

CASE REPORT

A 67-year-old male presented with a gradually progressive diminution of vision in both eyes over 6 months. Best-corrected visual acuity (BCVA) was finger counting at 1 meter in the right eye (RE) and 6/24 in the left eye (LE). Anterior segment examination was unremarkable in both eyes except for Grade 2 nuclear sclerosis in the LE (LOCS III). Fundus examination revealed an old macular scar in the RE and asteroid hyalosis in the LE, confirmed by B-scan ultrasonography [Figure 1]. The LE was selected for cataract surgery.

Figure 1.

Ultrasound B-scan image showing asteroid hyalosis as hyperechoic densities in the vitreous

The patient underwent manual SICS under peribulbar anaesthesia. A 6-mm by 2-mm superior scleral incision was created, and a well-constructed triplanar tunnel was fashioned to access the anterior chamber. The surgery proceeded uneventfully under the care of an experienced surgeon. At the end of the procedure, the anterior chamber was well formed, with no obvious wound leak detected. The conjunctiva adequately covered the main incision, and the side-port incision appeared well hydrated. One drop of 0.5% moxifloxacin was instilled. Because intraoperative corneal edema and Descemet folds were noted, sodium chloride 6% ointment was applied to the conjunctival cul-de-sac in the lower fornix and bulbar conjunctiva to reduce postoperative edema, and the eye was patched.

On postoperative day 1, visual acuity in the LE was 6/36. Slit-lamp examination revealed a mobile, whitish, semi-solid deposit in the anterior chamber located at the 11 o’clock position [Figure 2a]. Its mobility was confirmed by a change in position several hours later [Figure 2b]. The anterior chamber showed 1+ cells (SUN classification) with mild corneal edema, but no flare or increase in intraocular pressure. The patient was started on topical steroids, antibiotics, and nonsteroidal anti-inflammatory drugs.

Figure 2.

(a) Whitish semi-solid substance in anterior chamber at 11o’clock, (b) Change in position of the whitish substance

The appearance of the deposit suggested the possibility of calcium material from asteroid hyalosis migrating into the anterior chamber through intact zonules, especially as no posterior capsular rent or zonular dehiscence had occurred intraoperatively. Cortical material was considered unlikely as the deposit was not fluffy in appearance. Because the substance remained mobile and semisolid, an intraocular ointment globule was strongly suspected.

The patient underwent anterior chamber irrigation on postoperative day 1. The deposit was removed completely using visco-expression, and its consistency confirmed the diagnosis of ointment entry. Owing to limited laboratory facilities, chemical analysis of the material could not be performed. To ensure secure wound closure, the superior incision was reinforced with three interrupted 10-0 nylon sutures. The patient was discharged on postoperative day 3.

At 1-week follow-up, BCVA had improved to 6/12 in the LE, with a stable ocular examination and no delayed anterior chamber reaction [Figure 3].

Figure 3.

Postoperative picture of anterior chamber after removal of ointment

DISCUSSION

Complications following cataract surgery vary widely, but in this case, the contributing factors appear to include suboptimal wound sealing and postoperative eye squeezing, enabling ingress of ointment into the anterior chamber. A well-constructed triplanar tunnel is essential for achieving a self-sealing incision and maintaining anterior chamber stability.[7] Corneal wounds up to 4.0 mm are generally secure without suturing;[8] however, studies indicate that incisions created with a keratome may enlarge during surgical maneuvers in SICS.[9,10] This gradual widening may compromise wound integrity postoperatively.

Improper eye patching may also contribute by allowing involuntary squeezing, which can momentarily open the wound. In this case, both wound dynamics and postoperative manipulation likely played a role in ointment migration.

Previous reports of ointment in the anterior chamber describe presentations of TASS, secondary glaucoma, corneal decompensation, and cystoid macular edema.[5] TASS typically manifests within hours with characteristic limbus-to-limbus corneal edema, anterior chamber inflammation, and rapid visual deterioration.[4] In contrast, our patient showed none of these classic features, making this case distinct from earlier reports.

This case also raises the consideration of asteroid hyalosis migration into the anterior chamber. Although rare, such migration has been reported and attributed to posterior capsular rupture, zonular compromise, vitreous syneresis, or micro-spaces within intact zonules.[11] In this patient, the absence of intraoperative complications made this explanation unlikely. Furthermore, the semisolid, nonfluffy appearance of the material was more suggestive of ointment rather than cortical remnants or asteroid bodies.

Thus, accidental intraocular ointment entry should be considered when postoperative wound integrity is questionable or when eye squeezing is likely, especially when ointments are used instead of drops at the end of surgery. Prompt surgical removal is recommended to prevent potential inflammatory or toxic sequelae.

CONCLUSION

This case highlights the importance of meticulous wound construction, secure wound sealing, and a well-formed anterior chamber in cataract surgery. Proper postoperative eye patching is particularly crucial in patients receiving peribulbar anaesthesia to prevent squeezing-related wound gaping. The case also emphasizes the advantage of using eye drops rather than ointment at the end of surgery. Early recognition and immediate intervention can prevent serious complications, as demonstrated in this patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.