Cefuroxime Retinal Toxicity After Uneventful Phacoemulsification In A Patient With Weak Zonules

To present a case of retinal toxicity related to standard dose intracameral injection of cefuroxime after uneventful phacoemulsification in a patient with weak zonules.

A 48 year old female was seen complaining of bilateral gradual visual deterioration, more on the right eye (RE). She had a blunt trauma in the RE  2 years before and her medical history was free. BCVA was 2/10 (-6.00 sph, - 0.50 cyl x 60) in the RE and 6/10 (-1.00 sph, - 0.75 cyl x 90) in the LE. Slit lamp examination revealed a +2 nuclear cataract in the RE and a +1 nuclear cataract in the LE. Her pre-op OCT scans were normal. Axial lengths were 24.03 mm in the RE and 23.87 mm in the LE.

The patient underwent a RE uncomplicated phacoemulsification under topical anaesthesia during which weak zonules were noted. A one piece acrylic hydrophobic lens was successfully implanted in the bag. On the first post-operative day, she had clear cornea, mild anterior chamber reaction and clear vitreous. However, it was noted that BCVA in the RE was 2/10 (+0.50 sph,-0.50 cyl x 90). Retinal examination did not reveal any sign of retinal breaks or detachment. OCT examination demonstrated the presence of subretinal fluid in the macula with accompanying severe intraretinal fluid that was located in the outer nuclear and outer plexiform layers while the inner retinal layers were unaffected. Due to this characteristic tomographic pattern, cefuroxime retinal toxicity was suspected. On the second post-operative day, both subretinal and intraretinal fluid was significantly improved which was in agreement with the previously reported natural course of cefuroxime retinal toxicity. Fundus examination revealed discrete circular opaque areas temporal to the fovea which corresponded to focal folds in the neuroretina as seen with OCT. On the fifth post-operative day, subretinal and intraretinal fluid was completely resolved and the previously noted retinal folds were absent while BCVA had improved to 8/10. 6 weeks after the operation, BCVA was 10/10 (-0.75 sph,-0.50 cyl x 90) with normal retinal examination.

Cefuroxime retinal toxicity has been reported in a number of cases, mainly after inadvertent injection of a higher dose associated with dilution errors. Characteristic signs are the presence of subretinal fluid as well as intraretinal fluid that is mainly located in the outer nuclear and outer plexiform layers. It might exhibit retinal folds and in the majority of cases it resolves within one week usually without any significant effect on visual acuity. In our case, we used the standard dose of 0.1ml of 10.0mg/ml cefuroxime solution. We hypothesize that the presence of weak zonules in conjuction with the possibly liquified vitreous due to previous trauma, increased the passage of cefuroxime into the posterior segment and the retina.