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Acute post-cataract surgery endophthalmitis after using off-label cefuroxime as endophthalmitis prophylaxis

Poster Details

First Author: J.Abreu SPAIN

Co Author(s):    C. Pinto   E. Capote   P. Rocha   D. Perera   L. Cordoves  

Abstract Details



Purpose:

To report an acute post cataract surgery endophthalmitis after performing an uncomplicated phacoemulsification with posterior chamber (PC) intraocular lens (IOL) using off-label prophylactic intracameral cefuroxime (1mg/0.1 ml).

Setting:

Ophthalmology Service. University Hospital of the Canary Islands. Tenerife, Spain.

Methods:

Case report of a 82 year-old man referred to our department in October 2010 for right eye (RE) cataract surgical treatment. RE best corrected visual acuity (BCVA) was 0.4 , the slit -lamp examination showed a corticonuclear cataract , the intraocular pressure was 12 mmHg , and the fundoscopic exam was normal. As ophthalmological previous history the patient refers diplopia since 1993 (adduction OD + 60ยบ) secondary to head trauma, but compensated with prism glasses.

Results:

RE cataract surgery was performed as follows: peritopic anesthesia, three clear cornea incisions (two of 0.9 mm and one of 2.7 mm), anterior continuous curvilinear capsulorhexis (CCC) using forceps, facoemulsification, bimanual cannula cortex extraction, AcrySof ® IQ IOL monofocal SN60WF (Alcon, Forth Worth, Texas, USA) implantation, viscoelastic removal, incisions hydration and anterior camber cefuroxime injection. Immediate postoperative period was uneventful. One week after surgery RE BCVA was 1. Ten days post-op the patient referred RE visual acuity lost (hand motion at 30 cm) and pain. Right eye lit -lamp examination showed: conjunival hyperemia , tyndall +, 1 mm hypopyon and anterior-medium vitritis. At the fundoscopic exam we discovered areas of peripheral phlebitis and preretinal hemorrhages. Emergency pars plana vitrectomy, bacteriology sample for culture and intravitreal injection of vancomycin (1mg/0.1 ml) and ceftazidime (2mg/0.1 ml) were performed. Oral moxifloxacin and clarithromycin and topical ofloxacin and dexamethasone-cloranfenicol were prescribed. The culture was positive for CNS, showing the antibiogram resistance to beta-lactam (penicillin G, oxacillin) and sensitivity to empirical treatment previously initiated. At 3 weeks post-op non inflammatory clinical evolution was observed and RE BCVA was 0.8.

Conclusions:

CNS endophthalmitis suffered by our patient, despite the use of intracameral cefuroxime is within the microbial spectrum of endophthalmitis reported in the ESCRS study . Not having until 2013 of a preparation of 'on-label' cefuroxime could justify that the concentration used was inadequate as insufficient. Aprokan ® (Prokan ® in Spain, Laboratoires Thea , Clermont- Ferrand , France) was recently approved by the European Medicines Agency, and it is available as a commercial cefuroxime (50 mg powder for solution) for intracameral injection and at the end of cataract surgery. Early treatment of endophthalmitis following the recommendations of the ESCRS current protocol, significantly improves the prognosis of this feared complication of cataract surgery. FINANCIAL INTEREST: NONE

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