From the Eye Ear and Mouth Unit (EL, RW, DAHL), Maidstone and Tunbridge Wells NHS Trust, Kent; and St. Thomas’ Hospital (RW, DAHL), London, United Kingdom.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Tim Woolley for his anterior segment photographs.
Address correspondence to Edward J. Lee, FRCOphth, c/o Secretary to Mr. Laidlaw, Eye Ear and Mouth Unit, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane Maidstone, Kent, ME16 9QQ, United Kingdom.
Phacoemulsification cataract surgery is commonly performed with clear corneal incisions that are left unsutured at the completion of the procedure. Postoperative ingress of fluid or ointments, through small incisions that appear self-sealing at the time of surgery, has been described in several situations. We report a case of cystoid macular edema following the long-term retention of intracameral chloramphenicol ointment after routine small-incision phacoemulsification.
A 78-year-old man was referred for a second opinion with a history of a gradual deterioration in vision in his right eye during the preceding year. The patient described a central blurring but denied distortion.
He had undergone phacoemulsification cataract surgery in this same eye 6 years previously. The surgery, under peribulbar anesthesia, was performed by an experienced surgeon through a superior clear corneal incision with insertion of a foldable Akreos Fit IOL (Bausch & Lomb, Surrey, UK) into the bag. The procedure was uncomplicated and no corneal sutures were used. At the completion of surgery, chloramphenicol ointment was administered into the conjunctival fornix in addition to an injection of gentamicin and betamethasone. The eye was covered with an eye pad and shield to be left on overnight, and topical prednisolone acetate 1% and chloramphenicol eye drops were prescribed four times daily and tapered off during a 2-month period. The corrected acuity in his right eye was 6/5 by 12 weeks postoperatively with no drops. However, a spherical opacity was noted superiorly in the anterior chamber without any associated inflammation. This was believed to be chloramphenicol that had entered postoperatively from the conjunctival fornix because no other ointments had been used in the intervening period. This was observed and 1 year later the patient was discharged. The acuity in the right eye remained 6/6 with no signs of inflammation and with a normal intraocular pressure (IOP) (12 mm Hg).
The patient had no other ophthalmic history of note, apart from also undergoing left phacoemulsification cataract surgery, which was uneventful.
When referred to us 6 years later, he had corrected visual acuities of 6/24 in the right eye and 6/6 in the left eye. The superior opacity in the right anterior chamber was still evident, as shown in Figure 1. In addition, multiple similar but smaller opacities were evident overlying the iris and were also seen within the superior drainage angle on gonioscopy. The intraocular lens itself remained clear and unaffected. The IOPs were normal bilaterally (10 mm Hg in the right eye and 14 mm Hg in the left eye). Dilated funduscopy revealed right cystoid macular edema and a quiet vitreous cavity. The diagnosis of macular edema was confirmed with fluorescein angiography and optical coherence tomography, as shown in Figure 2A.
Figure 1. Anterior Chamber Photographs of the Patient’s Right Eye on Presentation with Cystoid Macula Edema. (A) A Superior Droplet of Presumed Chloramphenicol and (B) a Finer “dusting” of Large and Small Droplets (white and Black Arrows, Respectively) Are Seen Overlying the Iris.
Figure 2. Optical Coherence Tomography Images of the Right Macula (A) Before and (B) 7 Months Following Aspiration of the Anterior Segment Ointment.
Aspiration of the droplet and an anterior chamber washout was performed followed by a 2-month course of prednisolone (0.5%) and chloramphenicol (0.5%) eye drops. On the patient’s latest follow-up 7 months following the procedure, the cystoid macular edema was seen to resolve (central macular thickness = 240 μm compared with 577 μm preoperatively) (Fig. 2B), and the visual acuity improved to 6/12. There remained no signs of raised IOP or uveitis. The right macula had evidence of atrophic changes to the retinal pigment epithelium that may relate to the visual improvement being limited to 6/12.
Inadvertent entry of ointments has been described previously following intracapsular cataract surgery,1 radial keratotomy complicated by microperforations,2 and routine sutureless small-incision cataract surgery.3–7 The description provided previously by Wong et al. of intraocular chloramphenicol is similar to ours, with the chloramphenicol forming both a superior macroscopic droplet and a finer dusting over the iris surface and drainage angle.5 However, the case we describe is novel for both the 6-year period of follow-up and the subsequent development of cystoid macular edema.
The published consequences of intraocular ointments are variable, which is at least in part due to variations in the chemical nature and volume of the ointment retained. In some clinical reports, the ointment has remained in the anterior chamber for many years without apparent ill effect; others describe secondary uveitis and glaucoma, leading in some instances to enucleation.1,3–4,8 In a controlled animal study, Scheie et al. injected several common ointment bases into the anterior chambers of rabbit eyes.1 Consequences included inflammation, raised IOP, and corneal decompensation with loss of endothelial cells. There was a clear dose–effect relationship such that a small volume of 0.01 cc had little or no effect regardless of the type of ointment used, whereas 0.1 cc produced an overwhelming reaction in most eyes with prompt secondary glaucoma.
Two cases of chloramphenicol within the anterior chamber have been described in which the droplets were removed after approximately 10 weeks or on the same day following the cataract surgery.5–6 Wong et al. described a technique using cohesive viscoelastic (Healon; Abbot Medical Optics, Abbott Park, IL) and a lens guide to separate the chloramphenicol droplet from the intraocular lens without causing further disruption or dispersion of the droplet.5 The patients maintained good vision with no reported complications after 1 year and 6 weeks of follow-up, respectively. It is interesting that our patient had no evidence of raised IOP or clinical evidence of corneal decompensation following 6 years of intraocular chloramphenicol.
Careful consideration of wound structure and integrity is of the utmost importance with intraocular surgery to limit sight-threatening complications such as endophthalmitis, hypotony, and toxic anterior segment syndrome.7 The safety of modern cataract surgery has improved with the advent of smaller incision techniques, and clear corneal incisions are commonly left unsutured if they are found to be self-sealing at the completion of the procedure. However, it is important to remember that the self-sealing properties of unsutured clear corneal wounds are prone to compromise with postoperative variations in IOP or external pressure.8,9 If there is doubt over wound integrity, then a suture should be used. This case highlights a particular risk associated with unsecure wounds and postoperative ointments in the conjunctival fornix. Alternative routes of administering perioperative medications will avoid this particular complication but leave the eye at risk of others if the wound is not secure.
- Scheie HG, Rubenstein RA, Katowitz JA. Ophthalmic ointment bases in the anterior chamber: clinical and experimental observations. Arch Ophthalmol. 1965;73:36–42.
- Garzozi HJ, Muallem MS, Harris A. Recurrent anterior uveitis and glaucoma associated with inadvertent entry of ointment into the anterior chamber after radial keratotomy. J Cataract Refract Surg. 1999;25:1685–1687. doi:10.1016/S0886-3350(99)00268-0 [CrossRef]
- Riedl M, Maca S, Amon M, Nennadal T, Kruger A, Barisani T. Intraocular ointment after small-incision cataract surgery causing chronic uveitis and secondary glaucoma. J Cataract Refract Surg. 2003;29:1022–1025. doi:10.1016/S0886-3350(03)00060-9 [CrossRef]
- Chen KH, Lin SY, Li MJ, Cheng WT. Retained antibiotic ophthalmic ointment on an intraocular lens 34 months after sutureless cataract surgery. Am J Ophthalmol. 2005;139:743–745. doi:10.1016/j.ajo.2004.10.042 [CrossRef]
- Wong JG, Bank A. Surgical removal of intraocular antibiotic ointment after routine cataract phacoemulsification. J Cataract Refract Surg. 2006;32:890–892. doi:10.1016/j.jcrs.2006.01.071 [CrossRef]
- Aralikatti AK, Needham AD, Lee MW, Prasad S. Entry of antibiotic ointment into the anterior chamber after uneventful phacoemulsification. J Cataract Refract Surg. 2003;29:595–597. doi:10.1016/S0886-3350(02)01503-1 [CrossRef]
- Werner L, Sher JH, Taylor JR, et al. Toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery. J Cataract Refract Surg. 2006;32:227–235. doi:10.1016/j.jcrs.2005.12.093 [CrossRef]
- Sarayba MA, Taban M, Ignacio TS, Behrens A, McDonnell PJ. Inflow of ocular surface fluid through clear corneal cataract incisions: a laboratory model. Am J Ophthalmol. 2004;138:206–210. doi:10.1016/j.ajo.2004.03.012 [CrossRef]
- McDonnell PJ, Taban M, Sarayba M, et al. Dynamic morphology of clear corneal cataract incisions. Ophthalmology. 2003;110:2342–2348. doi:10.1016/S0161-6420(03)00733-4 [CrossRef]