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Ocular toxicity in cataract surgery because of inaccurate preparation and erroneous use of 50mg/ml intracameral cefuroxime

2011; Wiley; Volume: 90; Issue: 2 Linguagem: Inglês

10.1111/j.1755-3768.2010.02103.x

1755-3768

Olavi Pärssinen,

Ocular Diseases and Behçet’s Syndrome

Editor, Cefuroxime is a broad-spectrum cephalosporin antibiotic. Several studies have shown prophylactic intracameral cefuroxime to be effective in cataract surgery in preventing postoperative endophthalmitis (Barry et al. 2006; Pleyer & Geldsetzer 2008; Díez et al. 2009). Cefuroxime has also been shown to be safe when used in the recommended dose (Montan et al. 2002). This letter describes the ocular toxic effects in a series of patients who, because of a dilution and dosing error, received too high dose of intracameral cefuroxime at the end of cataract surgery. In the year 2002, vancomycin was routinely used as an antibiotic prophylaxis during cataract surgery in our clinic. However, one morning, when one of our eye surgeons was preparing for the day's cataract surgery, vancomycin was not available from the hospital pharmacy, and as a substitute the pharmacy recommended the use of cefuroxime. The operator asked the nurse to contact a hospital where cefuroxime (Zinacef®; GlaxoSmithKline, London, UK) was known to be in a routine use and ask for instructions on its use. The hospital faxed the dilution and usage orders, but unfortunately the second page of the fax showing the final dilution and recommended dosage failed to come through. The abbreviated guidelines of the fax which came through were as follows: Zinacef-solution for anterior chamber *can be preserved 12 h *15 ml balanced salt solution (BSS®; Alcon, Hünenberg, Switzerland) *Zinacef 750 mg -diluted with 10 ml NaCl -draw 0.4 ml away from the BSS bottle * add 0.4 ml of the Zinacef solution to the BSS bottle(15 ml containing 30 mg Zinacef and 0.5 ml contains 1 mg Zinacef) * give it 1–2 ml. Consequently, the assisting nurse totally misunderstood the recommendations and the operator did not double-check its correctness. The 750 mg of cefuroxime was diluted only into 15 ml of BSS, resulting in a concentration of 50 mg/ml. This solution was drawn into a 5-ml syringe thus containing 250 mg of cefuroxime and placed on the operating table. During that and the following day, different surgeons performed otherwise uneventfully cataract operations for 16 patients. At the end of surgery, the cefuroxime solution was instilled to flush and refill the anterior chamber. The surgeons did not document the exact amount of the solution used in different cases. In some cases, the whole 5 ml was used and in some cases only about 0.2 ml. A bilateral operation was performed for one patient. When the patients came for control on the first postoperative day, they all had cloudy oedematous corneas and poor vision. The use of cefuroxime was instantly terminated. The recorded complications were as follows: corneal oedema resolving in weeks, temporally raised intraocular pressure, pigment precipitates in the anterior chamber, loss of the endothelial cells of cornea, pigmentary changes on the retina, tritanopy type colour vision defect, defects in the dark adaptation, lowered threshold in the visual field, changes in the electroretinography and permanent loss of vision. Table 1 shows the preoperative and postoperative visual acuity values and postoperative intraocular pressures for the operated eyes and the recorded side-effects. In four eyes, postoperative vision was poorer that preoperative vision. Vision of 1.0 was attained only in one case. Electroretinography (ERG) taken from the patient 11 seven months after the operation showed a slight slowing of the a- and b-waves in the scotopic response of the rods. The same was seen in the a-waves of the compound response and in the latency (implicit time) of the first component of the fotopic cone response. In our cases, a varying amount of 50 mg/1 ml cefuroxime was injected into the anterior chamber at the end of surgery. It was calculated that the approximate doses of cefuroxime must have varied between 10 and 100 mg. It can be assumed corneal oedema and the loss of the endothelial cells were attributed to the toxic effects of cefuroxime on the corneal endothelial cells. Similarly, the pigment precipitation on the endothelium and on the anterior surfaces of the intraocular lens and iris as well as the pigment changes on the retina may have been attributed to the toxic effects of cefuroxime on the pigment cells of the eye. This adverse event reminds us how meticulous we have to be in the dilution and dosage of medicines and the importance of double-checking, especially when using off-label regimes. It was fortune in the present case that not all the patients suffered severe loss of vision and that the patient with bilateral cataract seemed to have suffered from less serious side-effects. All the patients were advised to apply for compensation from the national health insurance, and all who did so received financial compensation.