Intracameral Cefuroxime Prophylaxis After Cataract Surgery: Ethical And Medico-Legal Considerations In The Presence Of Known Retinal Toxicity

Intracameral cefuroxime is strongly supported by the European Society of Cataract and Refractive Surgeons (ESCRS) guidance for endophthalmitis prophylaxis. Emerging evidence of intracameral cefuroxime ocular toxic syndrome (ICOTS) in eyes with a disrupted intraocular barrier creates a surgeon’s dilemma: adherence may expose selected patients to foreseeable retinal toxicity, while deviation may increase infection risk and medico-legal scrutiny. We outline an ethical–medico-legal framework to integrate ICOTS risk into peri-operative decision-making, consent, and documentation while preserving evidence-based prophylaxis.

European cataract surgery practice in which intracameral cefuroxime is routinely used for endophthalmitis prophylaxis in line with ESCRS recommendations, focusing on disclosure standards and defensible documentation when patient-specific risk factors arise.

This clinical governance analysis consolidates published ICOTS evidence in cases where the intraocular barrier is compromised and aligns with ESCRS prophylaxis standards. It links the core dilemma to key medico-legal concepts such as foreseeability, duty to inform, standard of care, causation, and documentation, as well as to ethical principles like autonomy, beneficence, and non-maleficence. The project resulted in a risk-based consent addendum, a comprehensive documentation checklist, and a practical protocol for managing scenarios where risk factors are identified before or during surgery, such as posterior capsule rupture during anterior vitrectomy.

ICOTS displays a distinctive rapid-onset serous retinal detachment pattern, with imaging features that aid recognition and distinction from common postoperative issues. Evidence suggests that residual structural and functional deficits can persist even after fluid resolution, posing a significant risk of harm in vulnerable eyes. Medico-legally, following guidelines may not fully protect surgeons when risk factors are present; on the other hand, deviating from guidelines without documented reasoning and patient involvement could increase legal exposure if endophthalmitis develops. A targeted consent and documentation process supports defensible, guideline-aligned, personalized risk communication.

ESCRS guidance underpins best practices for intracameral cefuroxime prophylaxis. When a foreseeable ICOTS risk exists, responsible care requires more than mere compliance or deviation. A practical, risk-based approach may include: (1) identifying vulnerable eyes before or during surgery; (2) providing enhanced informed consent that covers ICOTS risk and potential long-term visual effects; (3) documenting the risk–benefit rationale and any intraoperative changes in risk profile; and (4) implementing a postoperative escalation plan (early OCT retinal imaging) to facilitate prompt recognition and transparent communication. This approach strengthens decision-making autonomy, supports patient safety, and minimizes medico-legal vulnerabilities.