TOXIC ANTERIOR STROMAL KERATITIS AFTER SYSTEMIC ALLERGIC REACTION TO LIDOCAINE

Hypersensitivity reactions to local anesthetics, particularly lidocaine, are rare. This report describes the clinical case of a young adult woman who presented with an atypical ocular manifestation, presumably related to a systemic hypersensitivity reaction after local injection of lidocaine.

Ophthalmology Department of Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Portugal.

Clinical case report.

A 42-year-old female with supraspinatus tendinosis was submitted to a local injection of methylprednisolone acetate and lidocaine hydrochloride in her left shoulder. She was otherwise healthy. A few minutes after the injection, the patient developed generalized weakness, tremors, palpitations, precordial discomfort and an itchy rash on her hands and feet and was sent to the emergency department. It was assumed as an allergic reaction to lidocaine and the patient was treated with intravenous hydrocortisone and clemastine with rapid relieve of her symptoms. During the night, the patient developed bilateral photophobia, ocular pain and conjunctival hyperemia. At the ophthalmological examination, she presented a corrected distance visual acuity of 20/20 and normal intraocular pressure in both eyes. During slit lamp observation, it was noted a discrete bilateral 360º peripheral anterior stromal corneal opacity. The patient was medicated with oral prednisolone 20 mg and cetirizine 20 mg, topical unpreserved dexamethasone 0.1%, topical cyclopentolate 1% and ocular lubrification. The next day she showed ocular symptoms relieve but the corneal opacity extended centrally, showing a diffusely distributed bilateral anterior stromal haze and reduced transparency, without signs of uveitis. The anterior segment optical coherence tomography demonstrated a homogenous hyperreflectivity localized on the anterior half of the corneal stroma. During follow-up time, the patient showed a favorable response to the medical treatment.

The initial perilimbal location of the corneal opacity, adjacent to the terminal capillary loops of the limbal vascular arcades, is compatible with an immune-related etiology, in this case probably related with a hypersensitivity reaction to lidocaine. Corticosteroids are the mainstay of therapy for the most common forms of interstitial keratitis and showed effectiveness in controlling the acute inflammatory symptoms and promoting the resolution of the condition.