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Recurrent anterior uveitis and glaucoma associated with inadvertent entry of ointment into the anterior chamber after radial keratotomy
Recurrent anterior uveitis and glaucoma associated with inadvertent entry of ointment into the anterior chamber after radial keratotomy Hanna J. Garzozi, MD, Marcus S. Muallem, MD, Alon Harris, PhD ABSTRACT Anterior uveitis and elevated intraocular pressure (IOP) occurred after radial keratotomy that was complicated by microperforation and penetration of antibiotic ophthalmic ointment into the anterior chamber. Anterior uveitis and IOP elevation were observed during the early postoperative follow-up and 41 and 61 months after surgery. All 3 attacks responded well to topical anti-inflammatory and antiglaucoma treatment. The probable causes of the uveitis and glaucoma in this case are discussed. J Cataract Refract Surg 1999; 25: 1685–1687 © 1999 ASCRS and ESCRS
I
ntraoperative and postoperative complications in patients having radial keratotomy (RK) are well documented.1 Microperforation has been reported in up to 35% of cases.2,3 Mild iridocyclitis is considered normal in the first few postoperative days.2 Moderate or severe iridocyclitis is rare; an association with microperforations has been suggested.4,5 In some patients, glaucoma develops after RK, as a result of perforation during surgery6 or long-term use of topical steroids after surgery.7 Penetration of ointment into the anterior chamber after intraocular surgery or penetrating injury has been reported.8,9 The most recent report8 of an occurrence of this rare complication was in 1973. In that study, glaucoma and uveitis with severe visual loss were the most serious consequences. Accepted for publication August 12, 1999. From the Department of Ophthalmology, Ha’Emek Medical Center, Afula, Israel (Garzozi, Muallem); Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA (Harris). Reprint requests to Hanna J. Garzozi, MD, Chairman, Department of Ophthalmology, Ha’Emek Medical Center, Afula 18101, Israel. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
We report a patient whose RK was complicated by microperforation and entrapment of ophthalmic antibiotic ointment in the anterior chamber. Three attacks of severe anterior uveitis and glaucoma arising from these primary complications responded well to local antiinflammatory and antiglaucoma treatment.
Case Report Two days after 8-incision RK in his right eye, a 25-yearold man reported severe pain, blurred vision, and swelling of the eyelids. In July 1993, he was operated on under topical anesthesia. The preoperative best corrected visual acuity (BCVA) was 20/20 (– 4.25 ⫹0.50 ⫻ 90). Surgery was complicated by a microperforation of the temporal incision. After the procedure was completed, the eye was dressed with tobramycin 0.3% (Tobrex威) ophthalmic ointment. On postoperative day 1, BCVA was 20/25 (⫹1.5). The surgeon noted conjunctival irritation with mucoid secretion and identified a bubble of ointment floating in the anterior chamber. On examination, BCVA was 20/20 (⫹1.25) and intraocular pressure (IOP), 28 mm Hg. There was swelling of the eyelids, ecchymosis of the conjunctiva, ciliary injection, mild corneal edema, and cells ⫹⫹ and flare ⫹⫹⫹ in the anterior chamber. A ball-shaped, 1.25 mm diameter ointment mass 0886-3350/99/$–see front matter PII S0886-3350(99)00268-0
CASE REPORTS: GARZOZI
was seen to float and move in the anterior chamber with eye and head movements. Mutton-fat and fibrin precipitations were seen on the corneal endothelium and lens capsule. Pupil reaction to light and fundus examination were normal. Ointment was aspirated from the anterior chamber using a McIntyre irrigation/aspiration cannula inserted through a limbal incision under local subconjunctival anesthesia. Relief of pain and resolution of the acute symptoms were prompt. In April 1994, the patient had uneventful photorefractive keratectomy in his left eye. In the right eye, uncorrected visual acuity was 20/25 and BCVA, 20/15 (⫹0.25 ⫹0.50 ⫻ 170). Intraocular pressure was 13 mm Hg. The patient was lost to follow-up in June 1994. In December 1996, the patient presented in the emergency room complaining of pain and blurred vision in his right eye. Uncorrected visual acuity was 20/90, BCVA was 20/40 (⫹0.50 ⫹1.25 ⫻ 170), and IOP was 36 mm Hg. Anterior uveitis with ciliary injection, mutton-fat precipitations on the corneal endothelium, and cells and flare in the anterior chamber were observed. A complete serological and immunological evaluation was carried out to identify a possible noniatrogenic cause for the patient’s iridocyclitis; the results were negative. Treatment with timolol maleate 0.5% (Timoptic威) twice daily and dexamethasone 0.1% (Sterodex威) 4 times daily relieved the uveitis symptoms in 7 to 8 days. Intraocular pressure remained normal (11 to 15 mm Hg) over 4 consecutive follow-up visits, and BCVA improved to 20/20. The left eye remained normal. In August 1998, the patient presented with another attack of anterior uveitis in the right eye; BCVA had deteriorated to 20/50 and IOP elevated to 32 mm Hg. The previous treatment was applied, and the new symptoms resolved in 2 weeks. On the patient’s last visit, BCVA in the right eye was 20/20 (⫹0.25 ⫹1.75 ⫻ 175) and IOP was 14 mm Hg without treatment. The iris texture appeared to be slightly atrophic and the pupil mildly deformed compared with those in the left eye. The endothelial cell count was 2010 cells/mm2 in the right eye and 2982 cells/mm2 in the left eye.
Discussion Most RK eyes have mild iritis with anterior chamber cell and flare reaction; this usually disappears over 1 to 2 weeks.2 Steroid responders have a transiently increased IOP.2 Significant post-RK iridocyclitis and glaucoma are extremely rare complications and have been reported in only 3 and 6 eyes, respectively.4 – 6,10 As in our case, these eyes had post-procedure microperforations; the severe iridocyclitis in 2 of the 3 eyes was attributed to instillation of fluorescein 0.25% drops 1 day after surgery.4 Microperforations are the most common intraoperative complication in RK surgery. The reported 1686
incidence varies between 0.006% and 0.35%.1 The Prospective Evaluation of Radial Keratotomy Study2 reported a 2.3% microperforation rate. In our case, the acute attack of iridocyclitis and glaucoma occurred immediately after RK and entrapment of the ocular ointment in the anterior chamber. The symptoms responded promptly to aspiration of the ointment mass, but there were 2 recurrences after long periods of asymptomatic remissions. The ointment was composed of tobramycin, chlorobutanol, mineral oil, and white petrolatum. Isolated tobramycin has not been described as an irritant material, but all 3 excipients in the ointment have.8,9,11 The entrapment of ophthalmic ointment has not been mentioned in studies of the outcome of RK and has not been reported since Fraunfelder and Hanna’s account in 1973.8 In that study, results of a survey of ophthalmologists’ use of topical eye ointments and the consequent complications were presented. The authors reported severe glaucoma and uveitis in 25 of 95 eyes examined by 65 ophthalmologists. In 9 eyes, ointment had to be removed, and 5 eyes were enucleated because of glaucoma, uveitis, or both. In the same study, the authors presented details of a study of the entrapment of ophthalmic ointments in rabbit eyes. The experimental findings confirm the clinical ones: The intraocular reaction to ointment depends on the amount and composition of the excipients, as well as of the active ingredient. In patients who experience microperforations during RK, installation of ophthalmic ointment could lead to complications such as we observed in our patient. In our case, 1 of the operating theater staff applied the ointment out of clinical habit when the first dressing was applied. We conclude that the recidivous elevation of IOP and the iridocyclitis are attributable to ocular ointment entrapment in the anterior chamber. Ointment should not be used when wound closure surgery after eye surgery or trauma is uncertain.
References 1. Rashid ER, Waring GO III. Complications of radial and transverse keratotomy. Surv Ophthalmol 1989; 34:73– 106 2. Waring GO III, Lynn MJ, Gelender H, et al. Results of the Prospective Evaluation of Radial Keratotomy
J CATARACT REFRACT SURG—VOL 25, DECEMBER 1999
CASE REPORTS: GARZOZI
3.
4.
5.
6.
7.
(PERK) study one year after surgery. Ophthalmology 1985; 92:177–196; discussion by MR Deitz, 196 –198 Deitz MR, Sanders DR, Marks RG. Radial keratotomy: an overview of the Kansas City study. Ophthalmology 1984; 91:467– 477; discussion by JH Krachmer, 477– 478 Brodsky ME, Bauerberg JM, Sterzovsky A. Case report: probable fluorescein-induced uveitis following radial keratotomy. J Refract Surg 1987; 3:28 –29 Starling JC, Hofmann RF. Case report: anterior uveitis and transient hyperopia following radial keratotomy. J Refract Surg 1986; 2:96 –98 Hersh PS, Kalevar V, Kenyon KR. Penetrating keratoplasty for severe complications of radial keratotomy. Cornea 1991; 10:170 –174 Haverbeke L. Assessing the efficacy of topical corticoste-
8.
9.
10.
11.
roids following radial keratotomy. Refract Corneal Surg 1993; 9:379 –382 Fraunfelder FT, Hanna C. Ophthalmic ointment. Trans Am Acad Ophthalmol Otolaryngol 1973; 77: 467– 475 Sugar HS, Airala MA. Introduction of some ophthalmic atropine ointments into the anterior chamber. Ann Ophthalmol 1972; 4:367–374 Busin M, Suarez H, Bieber S, McDonald MB. Overcorrected visual acuity improved by antiglaucoma medication after radial keratotomy. Am J Ophthalmol 1986; 101:374 –375 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 25, DECEMBER 1999
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I
ntraoperative and postoperative complications in patients having radial keratotomy (RK) are well documented.1 Microperforation has been reported in up to 35% of cases.2,3 Mild iridocyclitis is considered normal in the first few postoperative days.2 Moderate or severe iridocyclitis is rare; an association with microperforations has been suggested.4,5 In some patients, glaucoma develops after RK, as a result of perforation during surgery6 or long-term use of topical steroids after surgery.7 Penetration of ointment into the anterior chamber after intraocular surgery or penetrating injury has been reported.8,9 The most recent report8 of an occurrence of this rare complication was in 1973. In that study, glaucoma and uveitis with severe visual loss were the most serious consequences. Accepted for publication August 12, 1999. From the Department of Ophthalmology, Ha’Emek Medical Center, Afula, Israel (Garzozi, Muallem); Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA (Harris). Reprint requests to Hanna J. Garzozi, MD, Chairman, Department of Ophthalmology, Ha’Emek Medical Center, Afula 18101, Israel. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
We report a patient whose RK was complicated by microperforation and entrapment of ophthalmic antibiotic ointment in the anterior chamber. Three attacks of severe anterior uveitis and glaucoma arising from these primary complications responded well to local antiinflammatory and antiglaucoma treatment.
Case Report Two days after 8-incision RK in his right eye, a 25-yearold man reported severe pain, blurred vision, and swelling of the eyelids. In July 1993, he was operated on under topical anesthesia. The preoperative best corrected visual acuity (BCVA) was 20/20 (– 4.25 ⫹0.50 ⫻ 90). Surgery was complicated by a microperforation of the temporal incision. After the procedure was completed, the eye was dressed with tobramycin 0.3% (Tobrex威) ophthalmic ointment. On postoperative day 1, BCVA was 20/25 (⫹1.5). The surgeon noted conjunctival irritation with mucoid secretion and identified a bubble of ointment floating in the anterior chamber. On examination, BCVA was 20/20 (⫹1.25) and intraocular pressure (IOP), 28 mm Hg. There was swelling of the eyelids, ecchymosis of the conjunctiva, ciliary injection, mild corneal edema, and cells ⫹⫹ and flare ⫹⫹⫹ in the anterior chamber. A ball-shaped, 1.25 mm diameter ointment mass 0886-3350/99/$–see front matter PII S0886-3350(99)00268-0
CASE REPORTS: GARZOZI
was seen to float and move in the anterior chamber with eye and head movements. Mutton-fat and fibrin precipitations were seen on the corneal endothelium and lens capsule. Pupil reaction to light and fundus examination were normal. Ointment was aspirated from the anterior chamber using a McIntyre irrigation/aspiration cannula inserted through a limbal incision under local subconjunctival anesthesia. Relief of pain and resolution of the acute symptoms were prompt. In April 1994, the patient had uneventful photorefractive keratectomy in his left eye. In the right eye, uncorrected visual acuity was 20/25 and BCVA, 20/15 (⫹0.25 ⫹0.50 ⫻ 170). Intraocular pressure was 13 mm Hg. The patient was lost to follow-up in June 1994. In December 1996, the patient presented in the emergency room complaining of pain and blurred vision in his right eye. Uncorrected visual acuity was 20/90, BCVA was 20/40 (⫹0.50 ⫹1.25 ⫻ 170), and IOP was 36 mm Hg. Anterior uveitis with ciliary injection, mutton-fat precipitations on the corneal endothelium, and cells and flare in the anterior chamber were observed. A complete serological and immunological evaluation was carried out to identify a possible noniatrogenic cause for the patient’s iridocyclitis; the results were negative. Treatment with timolol maleate 0.5% (Timoptic威) twice daily and dexamethasone 0.1% (Sterodex威) 4 times daily relieved the uveitis symptoms in 7 to 8 days. Intraocular pressure remained normal (11 to 15 mm Hg) over 4 consecutive follow-up visits, and BCVA improved to 20/20. The left eye remained normal. In August 1998, the patient presented with another attack of anterior uveitis in the right eye; BCVA had deteriorated to 20/50 and IOP elevated to 32 mm Hg. The previous treatment was applied, and the new symptoms resolved in 2 weeks. On the patient’s last visit, BCVA in the right eye was 20/20 (⫹0.25 ⫹1.75 ⫻ 175) and IOP was 14 mm Hg without treatment. The iris texture appeared to be slightly atrophic and the pupil mildly deformed compared with those in the left eye. The endothelial cell count was 2010 cells/mm2 in the right eye and 2982 cells/mm2 in the left eye.
Discussion Most RK eyes have mild iritis with anterior chamber cell and flare reaction; this usually disappears over 1 to 2 weeks.2 Steroid responders have a transiently increased IOP.2 Significant post-RK iridocyclitis and glaucoma are extremely rare complications and have been reported in only 3 and 6 eyes, respectively.4 – 6,10 As in our case, these eyes had post-procedure microperforations; the severe iridocyclitis in 2 of the 3 eyes was attributed to instillation of fluorescein 0.25% drops 1 day after surgery.4 Microperforations are the most common intraoperative complication in RK surgery. The reported 1686
incidence varies between 0.006% and 0.35%.1 The Prospective Evaluation of Radial Keratotomy Study2 reported a 2.3% microperforation rate. In our case, the acute attack of iridocyclitis and glaucoma occurred immediately after RK and entrapment of the ocular ointment in the anterior chamber. The symptoms responded promptly to aspiration of the ointment mass, but there were 2 recurrences after long periods of asymptomatic remissions. The ointment was composed of tobramycin, chlorobutanol, mineral oil, and white petrolatum. Isolated tobramycin has not been described as an irritant material, but all 3 excipients in the ointment have.8,9,11 The entrapment of ophthalmic ointment has not been mentioned in studies of the outcome of RK and has not been reported since Fraunfelder and Hanna’s account in 1973.8 In that study, results of a survey of ophthalmologists’ use of topical eye ointments and the consequent complications were presented. The authors reported severe glaucoma and uveitis in 25 of 95 eyes examined by 65 ophthalmologists. In 9 eyes, ointment had to be removed, and 5 eyes were enucleated because of glaucoma, uveitis, or both. In the same study, the authors presented details of a study of the entrapment of ophthalmic ointments in rabbit eyes. The experimental findings confirm the clinical ones: The intraocular reaction to ointment depends on the amount and composition of the excipients, as well as of the active ingredient. In patients who experience microperforations during RK, installation of ophthalmic ointment could lead to complications such as we observed in our patient. In our case, 1 of the operating theater staff applied the ointment out of clinical habit when the first dressing was applied. We conclude that the recidivous elevation of IOP and the iridocyclitis are attributable to ocular ointment entrapment in the anterior chamber. Ointment should not be used when wound closure surgery after eye surgery or trauma is uncertain.
References 1. Rashid ER, Waring GO III. Complications of radial and transverse keratotomy. Surv Ophthalmol 1989; 34:73– 106 2. Waring GO III, Lynn MJ, Gelender H, et al. Results of the Prospective Evaluation of Radial Keratotomy
J CATARACT REFRACT SURG—VOL 25, DECEMBER 1999
CASE REPORTS: GARZOZI
3.
4.
5.
6.
7.
(PERK) study one year after surgery. Ophthalmology 1985; 92:177–196; discussion by MR Deitz, 196 –198 Deitz MR, Sanders DR, Marks RG. Radial keratotomy: an overview of the Kansas City study. Ophthalmology 1984; 91:467– 477; discussion by JH Krachmer, 477– 478 Brodsky ME, Bauerberg JM, Sterzovsky A. Case report: probable fluorescein-induced uveitis following radial keratotomy. J Refract Surg 1987; 3:28 –29 Starling JC, Hofmann RF. Case report: anterior uveitis and transient hyperopia following radial keratotomy. J Refract Surg 1986; 2:96 –98 Hersh PS, Kalevar V, Kenyon KR. Penetrating keratoplasty for severe complications of radial keratotomy. Cornea 1991; 10:170 –174 Haverbeke L. Assessing the efficacy of topical corticoste-
8.
9.
10.
11.
roids following radial keratotomy. Refract Corneal Surg 1993; 9:379 –382 Fraunfelder FT, Hanna C. Ophthalmic ointment. Trans Am Acad Ophthalmol Otolaryngol 1973; 77: 467– 475 Sugar HS, Airala MA. Introduction of some ophthalmic atropine ointments into the anterior chamber. Ann Ophthalmol 1972; 4:367–374 Busin M, Suarez H, Bieber S, McDonald MB. Overcorrected visual acuity improved by antiglaucoma medication after radial keratotomy. Am J Ophthalmol 1986; 101:374 –375 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 25, DECEMBER 1999
1687