Rare Case of "Toxic Anterior Segment Syndrome with Intracameral Moxifloxacin" reported

Moxifloxacin is a fourth-generation fluoroquinolone with broad spectrum activity against Gram-positive and Gram-negative bacteria. Annahita Amireskandari and team presented a case of TASS associated with intracameral preservative-free 0.5% moxifloxacin (Vigamox) during otherwise uncomplicated cataract surgery.

Case Report

A 74-year-old female presented as a referral from an outside ophthalmologist for persistent corneal edema and mydriatic pupil in the left eye after cataract surgery. According to the referring surgeon, the patient underwent routine phacoemulsification and insertion of a single-piece acrylic intraocular lens implant (IOL).

Approximately 0.2 ml intracameral preservative-free 1% lidocaine was instilled in the beginning of the case. Intracameral preservative-free moxifloxacin (Vigamox) was used to replace the anterior chamber at the end of the case (a total volume of approximately approximately 0.6 cc).

The surgeon was inadvertently given 0.5% undiluted Vigamox in the syringe instead of the ordered 0.1% concentration for all 7 of his cases that day. This error went unnoticed until the following day when all 7 patients had more than the anticipated amount of intraocular inflammation. The patient was noted to have significant corneal edema, elevated intraocular pressure (IOP), and anterior segment inflammation.

These signs persisted at her postoperative week one visit, raising concern for TASS. She was initially treated with topical prednisolone acetate, Vigamox, ketorolac, timolol, netarsudil (Rhopressa 0.02%), and hypertonic saline.

The anterior chamber inflammation resolved after several weeks, but the corneal edema and fixed, dilated pupil with transillumination defects persisted at 2 months postoperatively.

Per the referring provider, she was the only patient of the 7 that day to have persistent corneal edema and iris damage requiring further surgical intervention. To knowledge, no cultures or PCR was performed postoperatively. Of note, the patient had cataract surgery in the right eye 2 months prior with the same type of IOL and 0.6 cc of 0.1% intracameral Vigamox without complication.

The patient presented to this institution approximately two months after cataract surgery in the left eye. The uncorrected vision was 20/25 in the right eye and count fingers at 3 feet in the left eye.

The left pupil was dilated and slightly irregular with minimal to no reaction to light. The IOP was 15 mmHg in the right eye and 21 mmHg in the left eye.

The anterior and posterior segment exams were normal with a centered posterior chamber IOL on the right. The left eye had mild ptosis with mild conjunctival injection. The cornea was noted to have limbus-to-limbus bullous keratopathy. The anterior chamber was deep without frank inflammation.

The iris was fixed, dilated and slightly irregular with a large temporal transillumination defect. It was difficult to assess for endothelial pigment deposition given the diffuse corneal bullae. The posterior chamber IOL appeared to be well centered in the capsular bag. A hazy view posteriorly revealed no obvious abnormalities of the fundus.

It was evident that there was significant corneal endothelial damage, which led to the chronic bullous keratopathy and toxic injury to the iris, resulting in an atonic iris with an irregular pupil in the left eye.

After discussion with the patient, the decision was made to proceed with endothelial keratoplasty and iris repair. The patient did well postoperatively with a well-adhered graft at her postoperative day one visit and clear cornea at her postoperative week one visit.

At week one, the IOP was elevated to 28 mmHg so brimonidine was started twice daily (BID). The pressure fluctuated from 19-26 mmHg over the next 3 months so timolol BID was added as well. Prednisolone acetate was tapered slowly and eventually switched to fluorometholone daily. Visual acuity was 20/40-2 in the left eye at postoperative week one and month one visits.

At her most recent follow up 9 months after surgery, she remained on fluorometholone daily, timolol BID, and brimonidine BID. Her best corrected visual acuity was 20/25, and IOP was 18 mmHg in the left eye.

The etiology of toxic anterior segment syndrome in this case is thought to be due to instillation of a high volume (approximately 0.6 cc) of undiluted 0.5% intracameral Vigamox. However, other causes of intraocular inflammation should always be considered, especially infectious etiologies.

The use of intracameral antibiotics still varies greatly among surgeons. As reviewed here, there is conflicting data on the risks and benefits of intracameral moxifloxacin. Regardless of antibiotic choice, it is critical that the specific drug and concentration are checked at each step of preparation.

By verifying the antibiotic name, whether or not it is preservative free, its concentration, and the planned injection amount at each step of preparation, critical errors are less likely to occur.

The surgeon is ultimately the last check in this process and should also verify each of these parameters prior to instilling any medication in the eye. If an error does occur and results in significant anterior segment toxicity as seen with the case presented, initial aggressive control of inflammation and IOP is indicated. Even with a severe inflammatory response, it is often possible to have relatively good outcomes with proper management.

Source: Annahita Amireskandari, Andrew Bean, and Thomas Mauger; Hindawi Case Reports in Ophthalmological Medicine

DOI: https://doi.org/10.1155/2021/5526097