Intracameral entry of antibiotic ointment seen after cataract surgery

January 1, 2007
Omesh P. Gupta, MD, MBA

A 59-year-old male was referred for decreased vision and glare in his right eye 7 days after uneventful clear corneal (CC) phacoemulsification with IOL implantation. On postoperative day 1, his visual acuity was 20/25 in the affected eye. The anterior chamber reaction revealed 1+ cell and flare and the IOL was clear.

On postoperative day 7, the visual acuity had decreased to 20/100. A 2.5-mm semi-opaque, immobile, globular-shaped deposit was noted in the anterior chamber and appeared adherent to the IOL. A trial of topical prednisolone acetate 1% every 2 hours for 1 week was unsuccessful. The IOL was cleaned with the vitrector on postoperative day 10, and the deposit consistency and texture was similar to the antibiotic ointment administered at the end of the case.

The final visual acuity was 20/20 at postoperative week 3. A discussion of this unusual complication and a review of the literature is presented. This case also raises concerns about the integrity of CC incisions in the early postoperative period.

A 59-year-old male with a history of uncomplicated cataract extraction in his left eye was referred to Wills Eye at Jefferson, Philadelphia, with a 2-day history of decreased vision and glare in this right eye. Seven days prior, temporal CC phacoemulsification with IOL implantation was performed by an experienced cataract surgeon.

Topical anesthesia was used, and a 3-mm biplanar CC incision and uniplanar paracentesis was made. Phacoemulsification and capsulorhexis were uneventful, and a three-piece foldable silicone IOL was inserted into the capsular bag. Stromal hydration was performed on both wounds, and the finger tension was normal. Both wounds were tested with a dry cellulose sponge and were found to be watertight. No suture was placed, and polymyxin B/ neomycin/dexamethasone ophthalmic ointment was instilled into the inferior conjunctival fornix at the end of the case. A shield was placed over the eye without a pressure dressing.

On postoperative day 1, the uncorrected visual acuity (UCVA) was 20/25 in his right eye and 20/20 in his left eye. The IOPs by applanation were 8 mm Hg bilaterally. The conjunctiva was quiet, and the CC incisions appeared well apposed without gaping or leakage. The anterior chamber reaction revealed 1+ white blood cell and flare. The IOL was well-centered and clear. Slit lamp examination of the left eye revealed a deep and quiet anterior chamber and well-centered IOL. No deposit was noted within the anterior chamber or adherent to the IOL.

Examination

On ocular examination, the UCVA was 20/100 in the right eye and 20/20 in the left eye. Extraocular motility, pupil reactivity, and confrontation visual fields were within normal limits. The IOP by applanation was 18 mm Hg in the right eye and 11 mm Hg in the left eye. The slit lamp examination of the right eye revealed a quiet conjunctiva and CC incisions that were healing well. No gaping or wound distortion was noted. The anterior chamber demonstrated 1+ white blood cell and flare. A 2.5-mm semi-opaque, immobile, globular-shaped deposit was noted in the anterior chamber that appeared to be adherent to the anterior surface of the IOL. This deposit was through and slightly superior to the visual axis (Figure 1). The ocular examination of the left eye remained unchanged, and dilated fundus examination of both eyes was within normal limits.

Discussion and diagnosis

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