Cefuroxime-Related Hemorrhagic Occlusive Retinal Vasculitis After Cataract Surgery: Retrospective Case Series

Postoperative bacterial endophthalmitis is one of the most important vision-threatening complications after cataract surgery. It is known that the use of intracameral antibiotics has a great importance to prevent this situation. Cefuroxime is a second generation bactericidal agent that good compliance with the bacteria involved in postoperative endophthalmia. However, it should be considered that drugs administered into the eye may also have serious toxic effects. The aim of this report was to evaluate the clinical findings of the cases with hemorrhagic occlusive retinal vasculitis (HORV) observed as a result of intraoperative administration of intracameral cefuroxime during cataract surgery. 

      Cases undergoing intracameral cefuroxime injection at recommended doses during complicated cataract surgery, who developed postoperative HORV, were retrospectively evaluated. The patients were examined by biomicroscopic examination, fundus examination and fundus fluorescein angiography (FFA). 

All the patients had a history of complicated cataract surgery due to posterior capsule tear. All of  them underwent anterior vitrectomy, IOL implantation into the sulcus and administered intracameral cefuroxime at a  recommended dose of 0.1 ml (concentration: 1 mg / 0.1 mL). No other medication was used during surgery and also not added to the irrigation fluid. Fundus findings were normal in the preoperative period and post-op 1^th day.  Patients had the following clinical characteristics in  common: recent cataract surgery,  subacute onset after surgery (1-14 days), painless visual loss, mild to moderate anterior and intermediate uveitis, diffuse occlusive retinal vasculitis with predilection for venules, extensive intraretinal hemorrhages in ischemic regions, and negative ocular and systemic work-up.  Fundus fluorescent angiography (FFA) revealed hemorrhage-related hypofluoroscent areas, diffuse peripheral retinal vascular occlusion and diffuse peripheral ischemic areas. Panretinal photocoagulation was performed on the cases. One of the cases developed ocular neovascularization, rhegmatogenous retinal detachment and phthisis bulbi. No ocular neovascularization was observed in the other cases, but one of them developed optic atrophy.

Intracameral antibiotics, although used in some parts of the world, remain controversial .It is yet an important matter of discussion due to its increased costs, serious risks to the individual patient and its potential contribution to antibiotic resistance. Surgeons need to be conscious about this presentation formed by this destructive, vision-threatening condition caused by routine intracameral antibiotic injection. The outcomes of intracameral cefuroxime administrations should be evaluated, especially in cases with impaired posterior capsule integrity, since the amount of cefuroxime is not known in these cases. HORV may also be observed with intracameral cefuroxime injection at recommended doses in the complicated cataract surgery.