- Email: [email protected]
Intraocular ophthalmic ointment following anterior segment surgery
CASE REPORT
Intraocular ophthalmic ointment following anterior segment surgery Anita N. Shukla, MD, Mary K. Daly, MD, C. James McKnight, PhD, Thomas Freddo, OD, PhD
A 79-year-old man had uneventful phacoemulsification at an outside facility. During the postoperative period, his vision worsened secondary to chronic cystoid macular edema (CME). The patient was referred to the Veteran Affairs Boston Healthcare System for review 2 years and 4 months after the initial cataract procedure. The CME was confirmed, and a large pearly white globule that moved with changes in head position was noted. Surgical removal was performed, and nuclear magnetic resonance spectroscopy identified the unknown substance as petroleum jelly. The patient was treated with topical ketorolac tromethamine and prednisolone acetate with subsequent resolution of inflammation and CME, resulting in a corrected distance visual acuity of 20/25. The visual acuity was maintained 5 years after surgery. This case highlights the importance of ensuring the integrity of clear corneal incisions and suggests that use of topical ointment at the conclusion of a clear corneal case should be avoided. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:2218–2221 Published by Elsevier Inc. on behalf of ASCRS and ESCRS.
Several reports have described complications associated with intraocular ointment in the anterior chamber after cataract surgery.1–6 The reports make us question the stability of clear corneal incisions (CCIs) and the role of CCIs in the development of toxic anterior segment syndrome (TASS) and endophthalmitis by allowing microbes, preservatives, or foreign substances access to the anterior chamber. Submitted: June 25, 2011. Final revision submitted: July 7, 2011. Accepted: July 9, 2011. From the Veterans Affairs Boston Healthcare System (Shukla, Daly), the Department of Ophthalmology (Shukla, Daly) and the Department of Physiology and Biophysics (McKnight), Boston University School of Medicine, and Harvard Medical School (Daly), Boston, Massachusetts, USA; and the University of Waterloo, School of Optometry (Freddo), Waterloo, Ontario, Canada. Anita N. Shukla, MD, and Mary K. Daly, MD, contributed equally to this paper. Dr. John Lee and Dr. Edward Feinberg assisted in the care of the patient. Corresponding author: Mary Daly, MD, Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Office 8C-29, 150 South Huntington, Boston, Massachusetts 02130, USA. E-mail: [email protected].
2218
Published by Elsevier Inc. on behalf of ASCRS and ESCRS.
An increase in reports of TASS in 2006 led to the development of the TASS Task Force in association with the American Society of Cataract and Refractive Surgery. The TASS Task Force identified 3 main categories of focus: extraocular substances that enter the anterior chamber during or after surgery, products introduced into the anterior chamber as part of the surgery, and irritants on instrument surfaces.7 Included in the causes of delayed-onset postoperative sterile endophthalmitis was the use of postoperative ointment in clear corneal cases.8 In this report, we describe a case of TASS related to antibiotic ointment in the anterior chamber for 2 years and 4 months after cataract surgery. CASE REPORT In June 2003, a 79-year-old man had uneventful cataract surgery with implantation of an Acrysof intraocular lens (IOL), model SA60AT (Alcon Laboratories, Inc.), power 21.5 diopters in his right eye. The initial corrected distance visual acuity (CDVA) was 20/25. One week after surgery, the patient reported a cloud over his vision that moved with a change in his head position. It was hypothesized that there was an inclusion cyst in the superior angle of the right eye. One year later, the acuity worsened and the CDVA was 20/100. Cystoid macular edema (CME) was diagnosed and the patient started on topical steroids. He received 2 injections of sub-Tenon triamcinolone acetonide (Kenalog) over the subsequent year. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2011.09.015
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
Two years and 4 months after the cataract surgery, the patient was referred to the Veterans Affairs Boston Healthcare System, Department of Ophthalmology, for refractory CME and a “superior angle cyst.” On slitlamp examination, the anterior chamber had trace cells and a superior ovoid pearly white globule that moved with changes in head position (Figure 1, A). When the patient was supine, the globule floated to the central anterior chamber posterior to the corneal endothelium, resembling oil on water. Dozens of tiny clear globules were observed in the iris crypts and a few larger in the anterior vitreous (Figure 1, B and D). On gonioscopy, with the patient in the upright seated position at the slitlamp, rows of clear globules, too numerous to count, were viewed along the trabecular meshwork, most prominent superiorly (Figure 1, C). After informed consent was obtained, the patient was taken to the operating room for removal of the foreign substance as well as an anterior chamber washout. The largest globule, referred to as a superior angle cyst in the referral to our institution, was captured in a sterile specimen tube and sent to the McKnight Laboratory, Department of Physiology and Biophysics, Boston University School of Medicine. The specimen was dissolved in perdeuterated benzene and analyzed by 1-dimensional proton nuclear magnetic resonance (NMR) spectroscopy on a Bruker DMX-500 spectrometer to identify the substance. The spectra of the specimen and various ointments and vehicles including erythromycin ophthalmic ointment, bacitracin and polymyxin B (AK-PolyBac), and petroleum jelly were essentially identical (Figure 2). It was thus concluded that the unknown
2219
substance was petroleum jelly, an inactive vehicle used in many ophthalmic ointments. The patient was subsequently treated with topical ketorolac tromethamine (Acular) and prednisolone acetate, with improvement in inflammation and CME. The visual acuity improved initially to 20/30. Residual scattered tiny globules remained on the iris surface and in the superior angle on several follow-up visits. At the most recent visit in September 2010 (5 years after the removal of the ointment from the eye and 7 years and 4 months after the initial surgery), there were no globules on examination, including gonioscopy, no cystoid macular edema, and no inflammation. The patient is now 87, and the CDVA in the right eye is 20/25 2.
DISCUSSION Several reports1–6 have discussed the findings/sequelae of intraocular ointment in the anterior chamber. Chew et al.1 evaluated a case of recurrent anterior chamber inflammation 8 months after cataract surgery that required 2 IOL repositioning procedures. Subsequent development of a greasy film over the IOL led to IOL exchange at 27 months, with identification of hydrocarbons on the explanted IOL matching postoperative polymyxin B-neomycin–dexamethasone ointment. Chen et al.2 reported a case of visual acuity decline to 20/400 6 months after cataract surgery. An oily lump
Figure 1. Slitlamp examination views of the eye: A: External view. B: Anterior vitreous. C: Superior angle. D: Anterior vitreous. J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
2220
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
Figure 2. One-dimensional NMR spectra of specimen and controls. A: d-benzene. B: Specimen from patient’s eye. C: Commercial petroleum jelly. D: Bacitracin and polymyxin B ointment. E: Erythromycin ophthalmic ointment. All samples were dissolved in d-benzene, and the spectra were acquired on a Buker AMX-500 spectrometer at 25 C as the mean of 128 scans. The spectra were referenced to the residual benzene peak at 7.36 ppm, and the chemical shifts in the figure were offset to aid clarity.
was noted on the anterior surface of the IOL, and IOL exchange was performed 3 years after cataract surgery. Fourier transform infrared spectroscopy and Raman microspectroscopy identified the material as gentamicin (Garamycin) ointment. Of note, the incision had been enlarged to 5.0 mm during IOL implantation. Werner et al.3 reported a series of 8 patients who had clear corneal incision cataract surgery with 3-piece silicone IOL implantation by the same surgeon. All cases exhibited postoperative corneal edema; elevated intraocular pressure (IOP); and an oily, film-like material within the anterior chamber on day 1, necessitating future penetrating keratoplasty, IOL explantation, or trabeculectomy. Gas chromatography mass spectrometry of the lens extracts showed hydrocarbons similar to those seen in postoperative gentamicin sulfate 0.3% betamethasone disodium phosphate 0.1% ointment (Garasone). Riedl et al.4 reported a case of zinc neomycin ointment entry into the anterior chamber after uneventful cataract surgery. At 5 weeks, vitreous and cortex were noted in the anterior chamber and at 4 months, the patient had significant anterior uveitis and elevated IOP. At 6 months, a white round mass was noted in the anterior chamber and subsequently removed. The chromatogram of the specimen was compared with that of the ophthalmic ointment base lanolin and showed similar peaks. Although incisions may be competent at physiological levels of IOP, they fail when IOP is low.9 In
experiments with explanted human globes, higher IOPs were associated with close apposition of wound edges, with no tendency for wound leakage. However, at low IOPs, wound edges tended to gape, starting at the internal aspect of the wound. Ocular hypotony shortly after surgery allows corneal incisions to deform easily, inducing wound leak, further hypotony, and a resultant pressure gradient from the outside in. This provides a portal for bacteria or debris on the ocular surface to enter the anterior chamber.10 Using optical coherence tomography, McDonnell et al.11 confirmed variations in corneal wound morphology at various IOPs. Twenty percent of eyes experience IOP drops to 5 mm Hg or less within minutes to hours after surgery.12 Possible mechanisms include blinking, negative pressure on lid speculum removal, squeezing of eyelids, or vigorous eye rubbing.6 Such pressure gradients provide a mechanism for ointment entry into the eye after cataract surgery. Scheie et al.13 demonstrated the sequelae of ointment in the anterior chamber by injecting common ointment bases into the anterior chamber of rabbit eyes. They found that the amount of ointment instilled predicted the severity of the reaction. They showed that while 0.01 cc had little effect, 0.1 cc produced a severe inflammatory reaction. Interestingly, they demonstrated that after injection of petrolatum, a translucent mass formed in the upper angle causing localized corneal edema and absence of endothelium, very similar to the superior ovoid pearly white globule seen in our patient. To our knowledge, no reports have described the presence of antibiotic ointment in the anterior chamber over a 2-year 4-month period with excellent outcome. Complete resolution of CME and restoration of excellent visual acuity was achieved with ointment removal, anterior chamber washout, and topical steroid and topical nonsteroidal antiinflammatory eyedrops, which raises the question whether IOL exchange as performed in multiple prior reports is truly necessary. In our case, the largest globule was visibly removed in the operating room. In the immediate postoperative period, tiny globules on the iris surface and in the angle were noted, but over time, these resolved and were likely cleared through the trabecular meshwork. As Scheie et al.13 noted in their animal study, the eye may be able to tolerate and clear small amounts of petrolatum without ill effect. Prior case reports identify the unknown substance in the anterior chamber as a specific ointment. In our case, NMR spectroscopy confirmed that it is the neutral semisolid petrolatum, used as a protective vehicle and fatty substitute, which lingers in the eye for an extended period of time. It is reasonable to assume that the CME was secondary to the presence of petrolatum
J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
in the anterior chamber as it resolved when the petrolatum was removed more than 2 years later. Our case shows that the NMR is similar for many ophthalmic ointments as it is actually the vehicle, not the antibiotic component, that is retained for extended periods of time. Future studies might focus on the need for development of new medications for external application to the eye during the immediate postoperative periodd medications that have vehicles that are preservativefree and tolerated by the intraocular environment but have gel properties to ensure they remain in the cul-de-sac longer than drops. This case reviewed the integrity of CCIs, mechanics of postoperative endophthalmitis and TASS, current recommendations proposed by the TASS Task Force regarding the avoidance of ophthalmic ointment instillation at the conclusion of a clear corneal case, as well as the need for careful postoperative follow-up of phacoemulsification surgery. REFERENCES 1. Chew JJL, Werner L, Mackman G, Mamalis N. Late opacification of a silicone intraocular lens caused by ophthalmic ointment. J Cataract Refract Surg 2006; 32:341–346 2. Chen K-H, Lin S-Y, Li M-J, Cheng W-T. Retained antibiotic ophthalmic ointment on an intraocular lens 34 months after sutureless cataract surgery. Am J Ophthalmol 2005; 139:743–745 3. Werner L, Sher JH, Taylor JR, Mamalis N, Nash WA, Csordas JE, Green G, Maziarz EP, Liu XM. Toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery. J Cataract Refract Surg 2006; 32:227–235 4. Riedl M, Maca S, Amon M, Nennadal T, Kruger A, Barisani T. Intraocular ointment after small-incision cataract surgery causing chronic uveitis and secondary glaucoma. J Cataract Refract Surg 2003; 29:1022–1025 5. Aralikatti AKV, Needham AD, Lee MW, Prasad S. Entry of antibiotic ointment into the anterior chamber after uneventful phacoemulsification. J Cataract Refract Surg 2003; 29:595–597
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6. Wong JG, Bank A. Surgical removal of intraocular antibiotic ointment after routine cataract phacoemulsification. J Cataract Refract Surg 2006; 32:890–892 7. American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg 2007; 33:1095–1100. Available at: http://www.eyeworld.org/ewsupplementarticle. php?idZ200. Accessed July 13, 2011 8. Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg 2006; 32:324–333 9. Nichamin LD, Chang DF, Johnson SH, Mamalis N, Masket S, Packard RB, Rosenthal KJ. ASCRS white paper. What is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg 2006; 32:1556–1559 €m M, Wejde G, Stenevi U, Thorburn W, Montan P. 10. Lundstro Endophthalmitis after cataract surgery; a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology 2007; 114:866–870 11. McDonnell PJ, Taban M, Sarayba M, Rao B, Zhang J, Schiffman R, Chen Z. Dynamic morphology of clear corneal cataract incisions. Ophthalmology 2003; 110:2342–2348. Available at: http://chen.bli.uci.edu/publications/J50_Ophthalmology2003. pdf.pdf. Accessed July 13, 2011 12. Shingleton BJ, Wadhwani RA, O’Donoghue MW, Baylus S, Hoey H. Evaluation of intraocular pressure in the immediate period after phacoemulsification. J Cataract Refract Surg 2001; 27:524–527 13. Scheie HG, Rubenstein RA, Katowitz JA. Ophthalmic ointment bases in the anterior chamber; clinical and experimental observations. Arch Ophthalmol 1965; 73:36–42
J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
First author: Anita N. Shukla, MD Department of Ophthalmology, Veterans Affairs, Boston Healthcare System, South Huntington, Massachusetts, USA
Intraocular ophthalmic ointment following anterior segment surgery Anita N. Shukla, MD, Mary K. Daly, MD, C. James McKnight, PhD, Thomas Freddo, OD, PhD
A 79-year-old man had uneventful phacoemulsification at an outside facility. During the postoperative period, his vision worsened secondary to chronic cystoid macular edema (CME). The patient was referred to the Veteran Affairs Boston Healthcare System for review 2 years and 4 months after the initial cataract procedure. The CME was confirmed, and a large pearly white globule that moved with changes in head position was noted. Surgical removal was performed, and nuclear magnetic resonance spectroscopy identified the unknown substance as petroleum jelly. The patient was treated with topical ketorolac tromethamine and prednisolone acetate with subsequent resolution of inflammation and CME, resulting in a corrected distance visual acuity of 20/25. The visual acuity was maintained 5 years after surgery. This case highlights the importance of ensuring the integrity of clear corneal incisions and suggests that use of topical ointment at the conclusion of a clear corneal case should be avoided. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2011; 37:2218–2221 Published by Elsevier Inc. on behalf of ASCRS and ESCRS.
Several reports have described complications associated with intraocular ointment in the anterior chamber after cataract surgery.1–6 The reports make us question the stability of clear corneal incisions (CCIs) and the role of CCIs in the development of toxic anterior segment syndrome (TASS) and endophthalmitis by allowing microbes, preservatives, or foreign substances access to the anterior chamber. Submitted: June 25, 2011. Final revision submitted: July 7, 2011. Accepted: July 9, 2011. From the Veterans Affairs Boston Healthcare System (Shukla, Daly), the Department of Ophthalmology (Shukla, Daly) and the Department of Physiology and Biophysics (McKnight), Boston University School of Medicine, and Harvard Medical School (Daly), Boston, Massachusetts, USA; and the University of Waterloo, School of Optometry (Freddo), Waterloo, Ontario, Canada. Anita N. Shukla, MD, and Mary K. Daly, MD, contributed equally to this paper. Dr. John Lee and Dr. Edward Feinberg assisted in the care of the patient. Corresponding author: Mary Daly, MD, Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Office 8C-29, 150 South Huntington, Boston, Massachusetts 02130, USA. E-mail: [email protected].
2218
Published by Elsevier Inc. on behalf of ASCRS and ESCRS.
An increase in reports of TASS in 2006 led to the development of the TASS Task Force in association with the American Society of Cataract and Refractive Surgery. The TASS Task Force identified 3 main categories of focus: extraocular substances that enter the anterior chamber during or after surgery, products introduced into the anterior chamber as part of the surgery, and irritants on instrument surfaces.7 Included in the causes of delayed-onset postoperative sterile endophthalmitis was the use of postoperative ointment in clear corneal cases.8 In this report, we describe a case of TASS related to antibiotic ointment in the anterior chamber for 2 years and 4 months after cataract surgery. CASE REPORT In June 2003, a 79-year-old man had uneventful cataract surgery with implantation of an Acrysof intraocular lens (IOL), model SA60AT (Alcon Laboratories, Inc.), power 21.5 diopters in his right eye. The initial corrected distance visual acuity (CDVA) was 20/25. One week after surgery, the patient reported a cloud over his vision that moved with a change in his head position. It was hypothesized that there was an inclusion cyst in the superior angle of the right eye. One year later, the acuity worsened and the CDVA was 20/100. Cystoid macular edema (CME) was diagnosed and the patient started on topical steroids. He received 2 injections of sub-Tenon triamcinolone acetonide (Kenalog) over the subsequent year. 0886-3350/$ - see front matter doi:10.1016/j.jcrs.2011.09.015
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
Two years and 4 months after the cataract surgery, the patient was referred to the Veterans Affairs Boston Healthcare System, Department of Ophthalmology, for refractory CME and a “superior angle cyst.” On slitlamp examination, the anterior chamber had trace cells and a superior ovoid pearly white globule that moved with changes in head position (Figure 1, A). When the patient was supine, the globule floated to the central anterior chamber posterior to the corneal endothelium, resembling oil on water. Dozens of tiny clear globules were observed in the iris crypts and a few larger in the anterior vitreous (Figure 1, B and D). On gonioscopy, with the patient in the upright seated position at the slitlamp, rows of clear globules, too numerous to count, were viewed along the trabecular meshwork, most prominent superiorly (Figure 1, C). After informed consent was obtained, the patient was taken to the operating room for removal of the foreign substance as well as an anterior chamber washout. The largest globule, referred to as a superior angle cyst in the referral to our institution, was captured in a sterile specimen tube and sent to the McKnight Laboratory, Department of Physiology and Biophysics, Boston University School of Medicine. The specimen was dissolved in perdeuterated benzene and analyzed by 1-dimensional proton nuclear magnetic resonance (NMR) spectroscopy on a Bruker DMX-500 spectrometer to identify the substance. The spectra of the specimen and various ointments and vehicles including erythromycin ophthalmic ointment, bacitracin and polymyxin B (AK-PolyBac), and petroleum jelly were essentially identical (Figure 2). It was thus concluded that the unknown
2219
substance was petroleum jelly, an inactive vehicle used in many ophthalmic ointments. The patient was subsequently treated with topical ketorolac tromethamine (Acular) and prednisolone acetate, with improvement in inflammation and CME. The visual acuity improved initially to 20/30. Residual scattered tiny globules remained on the iris surface and in the superior angle on several follow-up visits. At the most recent visit in September 2010 (5 years after the removal of the ointment from the eye and 7 years and 4 months after the initial surgery), there were no globules on examination, including gonioscopy, no cystoid macular edema, and no inflammation. The patient is now 87, and the CDVA in the right eye is 20/25 2.
DISCUSSION Several reports1–6 have discussed the findings/sequelae of intraocular ointment in the anterior chamber. Chew et al.1 evaluated a case of recurrent anterior chamber inflammation 8 months after cataract surgery that required 2 IOL repositioning procedures. Subsequent development of a greasy film over the IOL led to IOL exchange at 27 months, with identification of hydrocarbons on the explanted IOL matching postoperative polymyxin B-neomycin–dexamethasone ointment. Chen et al.2 reported a case of visual acuity decline to 20/400 6 months after cataract surgery. An oily lump
Figure 1. Slitlamp examination views of the eye: A: External view. B: Anterior vitreous. C: Superior angle. D: Anterior vitreous. J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
2220
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
Figure 2. One-dimensional NMR spectra of specimen and controls. A: d-benzene. B: Specimen from patient’s eye. C: Commercial petroleum jelly. D: Bacitracin and polymyxin B ointment. E: Erythromycin ophthalmic ointment. All samples were dissolved in d-benzene, and the spectra were acquired on a Buker AMX-500 spectrometer at 25 C as the mean of 128 scans. The spectra were referenced to the residual benzene peak at 7.36 ppm, and the chemical shifts in the figure were offset to aid clarity.
was noted on the anterior surface of the IOL, and IOL exchange was performed 3 years after cataract surgery. Fourier transform infrared spectroscopy and Raman microspectroscopy identified the material as gentamicin (Garamycin) ointment. Of note, the incision had been enlarged to 5.0 mm during IOL implantation. Werner et al.3 reported a series of 8 patients who had clear corneal incision cataract surgery with 3-piece silicone IOL implantation by the same surgeon. All cases exhibited postoperative corneal edema; elevated intraocular pressure (IOP); and an oily, film-like material within the anterior chamber on day 1, necessitating future penetrating keratoplasty, IOL explantation, or trabeculectomy. Gas chromatography mass spectrometry of the lens extracts showed hydrocarbons similar to those seen in postoperative gentamicin sulfate 0.3% betamethasone disodium phosphate 0.1% ointment (Garasone). Riedl et al.4 reported a case of zinc neomycin ointment entry into the anterior chamber after uneventful cataract surgery. At 5 weeks, vitreous and cortex were noted in the anterior chamber and at 4 months, the patient had significant anterior uveitis and elevated IOP. At 6 months, a white round mass was noted in the anterior chamber and subsequently removed. The chromatogram of the specimen was compared with that of the ophthalmic ointment base lanolin and showed similar peaks. Although incisions may be competent at physiological levels of IOP, they fail when IOP is low.9 In
experiments with explanted human globes, higher IOPs were associated with close apposition of wound edges, with no tendency for wound leakage. However, at low IOPs, wound edges tended to gape, starting at the internal aspect of the wound. Ocular hypotony shortly after surgery allows corneal incisions to deform easily, inducing wound leak, further hypotony, and a resultant pressure gradient from the outside in. This provides a portal for bacteria or debris on the ocular surface to enter the anterior chamber.10 Using optical coherence tomography, McDonnell et al.11 confirmed variations in corneal wound morphology at various IOPs. Twenty percent of eyes experience IOP drops to 5 mm Hg or less within minutes to hours after surgery.12 Possible mechanisms include blinking, negative pressure on lid speculum removal, squeezing of eyelids, or vigorous eye rubbing.6 Such pressure gradients provide a mechanism for ointment entry into the eye after cataract surgery. Scheie et al.13 demonstrated the sequelae of ointment in the anterior chamber by injecting common ointment bases into the anterior chamber of rabbit eyes. They found that the amount of ointment instilled predicted the severity of the reaction. They showed that while 0.01 cc had little effect, 0.1 cc produced a severe inflammatory reaction. Interestingly, they demonstrated that after injection of petrolatum, a translucent mass formed in the upper angle causing localized corneal edema and absence of endothelium, very similar to the superior ovoid pearly white globule seen in our patient. To our knowledge, no reports have described the presence of antibiotic ointment in the anterior chamber over a 2-year 4-month period with excellent outcome. Complete resolution of CME and restoration of excellent visual acuity was achieved with ointment removal, anterior chamber washout, and topical steroid and topical nonsteroidal antiinflammatory eyedrops, which raises the question whether IOL exchange as performed in multiple prior reports is truly necessary. In our case, the largest globule was visibly removed in the operating room. In the immediate postoperative period, tiny globules on the iris surface and in the angle were noted, but over time, these resolved and were likely cleared through the trabecular meshwork. As Scheie et al.13 noted in their animal study, the eye may be able to tolerate and clear small amounts of petrolatum without ill effect. Prior case reports identify the unknown substance in the anterior chamber as a specific ointment. In our case, NMR spectroscopy confirmed that it is the neutral semisolid petrolatum, used as a protective vehicle and fatty substitute, which lingers in the eye for an extended period of time. It is reasonable to assume that the CME was secondary to the presence of petrolatum
J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
CASE REPORT: LATE POSTOPERATIVE TASS RELATED TO ANTIBIOTIC OINTMENT IN THE ANTERIOR CHAMBER
in the anterior chamber as it resolved when the petrolatum was removed more than 2 years later. Our case shows that the NMR is similar for many ophthalmic ointments as it is actually the vehicle, not the antibiotic component, that is retained for extended periods of time. Future studies might focus on the need for development of new medications for external application to the eye during the immediate postoperative periodd medications that have vehicles that are preservativefree and tolerated by the intraocular environment but have gel properties to ensure they remain in the cul-de-sac longer than drops. This case reviewed the integrity of CCIs, mechanics of postoperative endophthalmitis and TASS, current recommendations proposed by the TASS Task Force regarding the avoidance of ophthalmic ointment instillation at the conclusion of a clear corneal case, as well as the need for careful postoperative follow-up of phacoemulsification surgery. REFERENCES 1. Chew JJL, Werner L, Mackman G, Mamalis N. Late opacification of a silicone intraocular lens caused by ophthalmic ointment. J Cataract Refract Surg 2006; 32:341–346 2. Chen K-H, Lin S-Y, Li M-J, Cheng W-T. Retained antibiotic ophthalmic ointment on an intraocular lens 34 months after sutureless cataract surgery. Am J Ophthalmol 2005; 139:743–745 3. Werner L, Sher JH, Taylor JR, Mamalis N, Nash WA, Csordas JE, Green G, Maziarz EP, Liu XM. Toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery. J Cataract Refract Surg 2006; 32:227–235 4. Riedl M, Maca S, Amon M, Nennadal T, Kruger A, Barisani T. Intraocular ointment after small-incision cataract surgery causing chronic uveitis and secondary glaucoma. J Cataract Refract Surg 2003; 29:1022–1025 5. Aralikatti AKV, Needham AD, Lee MW, Prasad S. Entry of antibiotic ointment into the anterior chamber after uneventful phacoemulsification. J Cataract Refract Surg 2003; 29:595–597
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6. Wong JG, Bank A. Surgical removal of intraocular antibiotic ointment after routine cataract phacoemulsification. J Cataract Refract Surg 2006; 32:890–892 7. American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg 2007; 33:1095–1100. Available at: http://www.eyeworld.org/ewsupplementarticle. php?idZ200. Accessed July 13, 2011 8. Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg 2006; 32:324–333 9. Nichamin LD, Chang DF, Johnson SH, Mamalis N, Masket S, Packard RB, Rosenthal KJ. ASCRS white paper. What is the association between clear corneal cataract incisions and postoperative endophthalmitis? J Cataract Refract Surg 2006; 32:1556–1559 €m M, Wejde G, Stenevi U, Thorburn W, Montan P. 10. Lundstro Endophthalmitis after cataract surgery; a nationwide prospective study evaluating incidence in relation to incision type and location. Ophthalmology 2007; 114:866–870 11. McDonnell PJ, Taban M, Sarayba M, Rao B, Zhang J, Schiffman R, Chen Z. Dynamic morphology of clear corneal cataract incisions. Ophthalmology 2003; 110:2342–2348. Available at: http://chen.bli.uci.edu/publications/J50_Ophthalmology2003. pdf.pdf. Accessed July 13, 2011 12. Shingleton BJ, Wadhwani RA, O’Donoghue MW, Baylus S, Hoey H. Evaluation of intraocular pressure in the immediate period after phacoemulsification. J Cataract Refract Surg 2001; 27:524–527 13. Scheie HG, Rubenstein RA, Katowitz JA. Ophthalmic ointment bases in the anterior chamber; clinical and experimental observations. Arch Ophthalmol 1965; 73:36–42
J CATARACT REFRACT SURG - VOL 37, DECEMBER 2011
First author: Anita N. Shukla, MD Department of Ophthalmology, Veterans Affairs, Boston Healthcare System, South Huntington, Massachusetts, USA