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

Abstract

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.

Background

Acute exudative macular oedema following uncomplicated phacoemulsification cataract surgery is rare. Such an eventuality, directly attributable to cataract surgery, has been reported following inadvertent intracameral injection of a toxic dose of cefuroxime.¹ Injection of intracameral cefuroxime (1 mg/0.1 mL) at the end of cataract surgery has become the accepted norm in the UK, following the publication of the ESCRS study on endophthalmitis prophylaxis after phacoemulsification cataract surgery.² However, there are a few case reports whereby patients receiving even a standard dose of intracameral cefuroxime develop macular oedema. Our case highlights the practise of discarding excess cefuroxime onto the corneal wound or ocular surface as a possible causative factor.

Case presentation

A white man in his 80s presented to the ophthalmology urgent care department 1 day after uncomplicated cataract surgery to his right eye. He reported seeing a white spot surrounded by a black circle in the field of vision of the operated eye. It appeared immediately after surgery and his visual acuity was reduced. The patient had a significant medical history consisting of atrial fibrillation, systemic hypertension, asthma, chronic obstructive respiratory disease, arthritis, chronic kidney disease, varicose veins and eczema. There was no history of diabetes mellitus. His regular medications included lisinopril, bisoprolol, amlodipine, rivaroxaban, tamsulosin, sildenafil as well as fluticasone/salmeterol and salbutamol inhalers. The patient had started using Maxitrol (dexamethasone 0.1% with neomycin) eye drops prior to presentation. The patient had cataract surgery to the fellow eye 5 months earlier where a standard dose of 1 mg/0.1 mL cefuroxime sodium was given intracamerally with no reported postoperative complications. He had no other ocular history of note.

Phacoemulsification and intraocular lens insertion to the right eye was performed by an experienced surgeon under sub-Tenon’s anaesthesia. Floppy iris was noted intraoperatively but the procedure was uncomplicated. Phacoemulsification time was 33 s, with an average power of 27%. A standard dose of 1 mg/0.1 mL cefuroxime sodium was given intracamerally at the end of the procedure.

At presentation, his best-corrected visual acuity was 6/36 in the right eye and 6/6 in the left eye. On slit-lamp examination, the conjunctiva in the right eye was mildly hyperaemic and except for a few Descemet’s folds in the cornea, the anterior segment was within normal limits. The intraocular lens (IOL) was well centred with an intact posterior capsule. The intraocular pressure measured was 12 mm Hg by applanation tonometry. Dilated fundus examination revealed a single air bubble in the superior vitreous cavity. The macula appeared tented and oedematous. There was no evidence of vitritis, retinal tears or detachment on peripheral retinal examination. The left eye was unremarkable.

Investigations

High-definition optical coherence tomography (OCT) showed evidence of serous retinal detachment with a large collection of subretinal and intraretinal fluid in the foveal region (figure 1). Central retinal thickness was recorded as 769 µm. There was normal vitreoretinal adhesion at the macula, with no evidence of traction at the vitreoretinal interface.

Figure 1.

Standard-definition OCT at presentation showing a large collection of intraretinal and subretinal fluid at the fovea in the right eye. ILM-RPE, internal limiting membrane - retinal pigment epithelium; OCT, optical coherence tomography; OD, oculus dexter; OS, oculus sinister.

Differential diagnosis

The working diagnosis at presentation included: (1) acute vitreofoveal traction, (2) cefuroxime toxicity and (3) other causes of serous retinal detachment. Standard-definition OCT imaging did not adequately define the vitreoretinal interface. The differential diagnosis of vitreofoveal traction was ruled out by high-definition OCT images (figure 2). Other causes of serous retinal detachment were felt to be less likely due to the absence of any other signs. Cefuroxime toxicity was presumed to be the diagnosis in this case. The operating surgeon confirmed the injection of the standard dose and the nurse preparing it confirmed normal protocol in preparing the medication. There were no patients with a similar problem who underwent surgery that day. The patients presenting symptom of a white dot with a black circle was attributed to the air bubble identified in the vitreous cavity.

Figure 2.

High-definition optical coherence tomography (OCT) at presentation revealing normal vitreoretinal adhesion at the macula with no evidence of traction at the vitreoretinal interface.

Treatment

The patient was treated with topical prednisolone 1% four times a day, ketorolac 0.5% three times a day and chloramphenicol 0.5% four times a day in place of the Maxitrol drops he had been prescribed postoperatively.

Outcome and follow-up

At follow-up 3 weeks later, his visual acuity had significantly improved to 6/7.5 unaided. There was 1+ cells and 1+ flare noted in the anterior chamber with an intraocular pressure of 16 mm Hg. OCT scan showed complete resolution of the serous retinal detachment with no evidence of intraretinal or subretinal fluid (figure 3). The central retinal thickness had reduced to 248 µm. The patient was advised to continue topical prednisolone 1% four times a day and ketorolac 0.5% three times a day until his next review 1 month later.

Figure 3.

Standard-definition OCT at follow-up 3 weeks following presentation showing complete resolution of the intraretinal and subretinal fluid. ILM-RPE, internal limiting membrane - retinal pigment epithelium; OCT, optical coherence tomography; OD, oculus dexter; OS, oculus sinister.

Discussion

Acute macular oedema after routine phacoemulsification cataract surgery is not a known clinical entity. This presentation is different to the postoperative cystoid macular oedema (Irvine-Gass syndrome) which usually develops 3–4 weeks post surgery.³ Macular oedema arising from the inadvertent injection of a high dose of intracameral cefuroxime has been reported in the literature. One published case series of 19 patients receiving an erroneous dose of either 10 or 12.5 mg cefuroxime showed one case of serous macular detachment.⁴ In another case series of 13 patients unintentionally receiving 9 mg of cefuroxime, 6 patients had evidence of macular oedema 1 day postoperatively.⁵

There were few published cases in the last decade of presumed cefuroxime toxicity after cataract surgery with a standard dose.^6–8 All these cases presented with similar OCT features to our case 1–2 days post surgery. One case series reports a surgeon who was hydrating the corneal wounds with cefuroxime instead of basic salt solution, resulting in macular toxicity.⁹

The practice of preparation, dilution and discarding of excess cefuroxime in theatre needs attention. In our theatre, the preparation follows an agreed protocol. The 1 mg/0.1 mL cefuroxime solution is drawn into a 1 mL syringe and handed to the surgeon. The volume drawn varies between 0.3 and 0.7 mL while just 0.1 mL is required for injection into the anterior chamber. Some surgeons will squirt the excess solution onto the corneal surface or wound edge, while others discard it away from the patient’s eye. With the former practice, there is a potential for more than the intended 0.1 mL to enter the anterior chamber. As proposed by Aslankurt et al, this mechanism may be at play when cefuroxime is simply squirted onto the wound edge, not only if it is used for wound hydration.⁹ Like many surgeons, the surgeon in our case did squirt the excess cefuroxime onto the ocular surface prior to intracameral injection.

Interestingly, our patient had the same dose of intracameral cefuroxime given to the fellow eye, by the same surgeon, 5 months prior, without any known adverse effect. This anomaly was reported by another investigator where bilateral surgery produced toxicity in just one eye.¹⁰

Learning points.

• Acute serous detachment with intraretinal oedema of the macula in the immediate postoperative period is a rare clinical entity.

• The exact pathophysiology remains unclear but the possibility of cefuroxime causing an abnormal response in some individuals, even with normal dosage, remains a viable proposition.

• It is advisable not to prime the syringe containing cefuroxime by squirting the excess amount onto the corneal wound or surface as this may inadvertently increase the dose entering the anterior chamber.

• The outcome of this clinical entity is good, with restoration of normal vision within a few weeks.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).