EPIRETINAL DEPOSITS POST CATARACT EXTRACTION Umesh C. Behera, MS, Rathinam R. Sivakumar, FAMS, PhD, Lalitha Prajna, MD, Niraj Agrawal, MS, Renu P. Rajan, MD
Purpose: To report two unusual cases of epiretinal deposit post cataract surgery. Methods: Retrospective identification of an unusual complication in patients who had cataract extraction recently with intraoperative complications. Results: Two patients were identified with epiretinal deposits after cataract extraction where the posterior capsule barrier was breached. Inflammation was limited to the posterior segment, and investigative workup for infective causes was negative. No intraocular antibiotics had been used. In both the cases, hydroxypropyl methylcellulose was used as the viscoelastic substance. Conclusion: The authors report rare posterior segment toxicity in cataract surgeries complicated with intraoperative breach of posterior capsule barrier and hydroxypropyl methylcellulose use. RETINAL CASES & BRIEF REPORTS 7:359–361, 2013
not required for this review, informed consent was obtained from each patient before undergoing any surgical intervention.
From the Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India.
E
piretinal deposits in postoperative endophthalmitis is believed to be a result of drug precipitation with concurrent administration of vancomycin and ceftazidime into the vitreous cavity.1 We present two cases with epiretinal deposits after cataract extraction unrelated to intravitreal antibiotic use, rather secondary to presumed intraoperative hydroxypropyl methylcellulose (HPMC) egress into the vitreous cavity.
Case Reports Case 1 A healthy 67-year-old man with nuclear sclerosis, pseudoexfoliation, and phacodonesis underwent small incision cataract surgery and intraocular lens implantation with capsular tension ring support in the left eye. A zonular dialysis involving 4 clock hours was noted intraoperative. Viscoelastic substance (HPMC) was used to stabilize the anterior chamber. At the end of the surgery, no prophylactic intracameral or subconjunctival antibiotics were used. The postoperative vision improved to 20/30. He was discharged from the hospital with topical antibiotics and corticosteroids. A fortnight later, he presented with complaints of floaters in the operated eye without any associated ocular pain. The vision was maintained at 20/30; anterior chamber showed cells (1+) without any conjunctival injection. Fundus examination revealed white epiretinal deposits in the inferior retina with mild vitritis and vitreous membranes (Figure 1). Presumed to be an atypical form of acute postoperative endophthalmitis, vitreous biopsy was collected for smear, culture, and polymerase chain reaction. However, no evidence of infection could be established. A complete systemic workup to locate an endogenous source of infection was negative.
Materials and Methods An unusual posterior segment complication was identified retrospectively in two patients who had cataract extraction recently. The medical records and available fundus photographs were reviewed. Although institutional review board’s oversight was Presented at Sixth Asia Pacific Vitreoretina Society Congress, Hyderabad, India, December 1–3, 2011. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Umesh C. Behera, MS, L V Prasad Eye Institute, Patia, Bhubaneswar, Odisha 751024, India; e-mail: umeshcbehera@ gmail.com
Case 2 A healthy 51-year-old woman presented with floaters and central scotoma in the left eye 2 weeks post phacoemulsification with single-piece acrylic lens implantation. She was operated for a
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Fig. 2. Fundus photograph of the left eye (Case 2) shows patchy epiretinal deposits presumed to be a result of HPMC egress into vitreous cavity through posterior capsular defect during cataract extraction.
Fig. 1. Composite fundus image of the left eye (Case 1) shows epiretinal deposits in inferior retina mimicking bacterial colonies.
posterior subcapsular cataract with a corrected vision of 20/60. Review of the operative case record revealed intraoperative posterior capsular rupture. No vitreous disturbance was documented. The viscoelastic substance used was HPMC. No prophylactic intracameral or subconjunctival antibiotic was used. The vision had improved to 20/20 postoperative. The floaters and central scotoma were gradually progressive without any associated pain in the ensuing weeks. On examination, her vision had dropped to finger counts at 1 m. There was no evidence of conjunctival injection or corneal edema. Cells (1+) in anterior chamber and a posterior capsular defect were noted on biomicroscopy. Examination of posterior segment revealed Grade 2 vitritis and multiple, patchy, white deposits on the retinal surface (Figure 2). Pars plana vitrectomy and peeling of the deposits was done to restore her vision (see Video, Supplemental Digital Content 1, http://links.lww.com/ICB/A5). The vitreous sample as well as the peeled deposits collected during vitrectomy were sent for cytology, microbial culture, and polymerase chain reaction. There was no growth of bacteria or fungi on culture. Both nested and uniplex polymerase chain reaction for bacteria and fungi was negative. Smear cytology of the peeled sample with hematoxylin and eosin staining revealed numerous histiocytes with abundant cytoplasm engulfing and surrounding the presumed HPMC deposits, representative of a granulomatous reaction (Figure 3). A complete systemic evaluation to rule out endogenous endophthalmitis turned out negative.
Discussion We report two patients with an atypical presentation of epiretinal deposits after cataract extraction where the posterior capsule barrier was breached. A similar presentation of epiretinal deposits has been described,2
where the culture of vitreous specimen had not grown any organisms. As in the previous report and in our patients, the inflammation was localized to the posterior segment without corresponding anterior segment involvement, mimicking a state of posterior segment toxic anterior segment syndrome. The presence of vitritis with white deposits on retina may represent acute postoperative endophthalmitis, but the absence of prominent anterior segment inflammation of postoperative endophthalmitis (lid edema, conjunctival congestion, corneal edema, anterior chamber fibrinous membrane/hypopyon, or ocular pain) and the negative culture and polymerase chain reaction results prompted us to suspect a toxic reaction to inadvertent viscoelastic substance egress into the vitreous cavity that spared the anterior segment from the inflammation. In our belief, if it was of infective origin, then it would have presented with a corresponding level of vitritis or anterior segment inflammation. Although the time of presentation in these two patients does not support a state of toxic anterior segment syndrome that is known to confine itself to the anterior segment and present in early postoperative period,3 the timing of a similar state in the posterior segment is not described. Use of viscoelastic substance is one of the etiological factors for toxic anterior segment syndrome. The ones in common use are HPMC and sodium hyaluronate. Hydroxypropyl methylcellulose, being a plant derivative, is not metabolized in the human body.4 Hence, an inadvertent retention in the anterior chamber after cataract extraction would complicate the postoperative period with a rise in inflammation and intraocular pressure. Although a similar behavior of HPMC in vitreous cavity is not evaluated in humans, animal studies in rabbits have demonstrated white
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membranes, and the retinal deposits were because of viscoelastic (HPMC) egress into the vitreous cavity. The distinct pattern of epiretinal distribution could be attributed to the cohesive property of HPMC. As observed in phacoanaphylactic endophthalmitis,6 these atypical presentations were presumed to be a rare inflammatory response to HPMC that occurred under special conditions, and in certain individuals, if HPMC was universally toxic to the eye, epiretinal white deposits would occur regularly after disruption of lens capsule or zonules during cataract extraction. Key words: epiretinal deposits, endophthalmitis, viscoelastic substance. Fig. 3. Photomicrograph of the smear shows sheets of histiocytes with abundant cytoplasm, some of which are seen engulfing (#) and surrounding (*) presumed HPMC deposits on retina (hematoxylin and eosin).
precipitates, vitreous bands, and inflammation.5 Sodium hyaluronate conversely being a natural biologic tissue component of vitreous does not incite an inflammatory response when in vitreous. The failure to demonstrate the presence of HPMC traces in the ocular samples on size exclusion chromatography or gas chromatography was a major limitation in this report. But based on the clinical circumstance, the cytology smear, and evidence in the literature, we presume that the vitreous inflammation,
References 1. Javey G, Albini TA, Moshfeghi AA, et al. Spectral-domain optical coherence tomography appearance of preretinal aggregation of intravitreal antibiotics. Retina 2010;30:184–185. 2. Behera UC, Shukla D, Kim R. In their patient, as in our patient, vitreous specimens were culture negative. Retina 2010;30: 1327–1328. 3. Mamalis N, Edelhauser HF, Dawson DG, et al. Toxic anterior segment syndrome. J Cataract Refract Surg 2006;32:324–333. 4. Hütz WW, Eckhardt HB, Kohnen T. Comparison of viscoelastic substances used in phacoemulsification. J Cataract Refract Surg 1996;22:955–959. 5. Koster R, Stilma JS. Comparison of vitreous replacement with Healon and with HPMC in rabbit’s eyes. Doc Ophthalmol 1986;64:13–17. 6. Marak GE Jr. Phacoanaphylactic endophthalmitis. Surv Ophthalmol 1992;36:325–339.
Purpose: To report two unusual cases of epiretinal deposit post cataract surgery. Methods: Retrospective identification of an unusual complication in patients who had cataract extraction recently with intraoperative complications. Results: Two patients were identified with epiretinal deposits after cataract extraction where the posterior capsule barrier was breached. Inflammation was limited to the posterior segment, and investigative workup for infective causes was negative. No intraocular antibiotics had been used. In both the cases, hydroxypropyl methylcellulose was used as the viscoelastic substance. Conclusion: The authors report rare posterior segment toxicity in cataract surgeries complicated with intraoperative breach of posterior capsule barrier and hydroxypropyl methylcellulose use. RETINAL CASES & BRIEF REPORTS 7:359–361, 2013
not required for this review, informed consent was obtained from each patient before undergoing any surgical intervention.
From the Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, India.
E
piretinal deposits in postoperative endophthalmitis is believed to be a result of drug precipitation with concurrent administration of vancomycin and ceftazidime into the vitreous cavity.1 We present two cases with epiretinal deposits after cataract extraction unrelated to intravitreal antibiotic use, rather secondary to presumed intraoperative hydroxypropyl methylcellulose (HPMC) egress into the vitreous cavity.
Case Reports Case 1 A healthy 67-year-old man with nuclear sclerosis, pseudoexfoliation, and phacodonesis underwent small incision cataract surgery and intraocular lens implantation with capsular tension ring support in the left eye. A zonular dialysis involving 4 clock hours was noted intraoperative. Viscoelastic substance (HPMC) was used to stabilize the anterior chamber. At the end of the surgery, no prophylactic intracameral or subconjunctival antibiotics were used. The postoperative vision improved to 20/30. He was discharged from the hospital with topical antibiotics and corticosteroids. A fortnight later, he presented with complaints of floaters in the operated eye without any associated ocular pain. The vision was maintained at 20/30; anterior chamber showed cells (1+) without any conjunctival injection. Fundus examination revealed white epiretinal deposits in the inferior retina with mild vitritis and vitreous membranes (Figure 1). Presumed to be an atypical form of acute postoperative endophthalmitis, vitreous biopsy was collected for smear, culture, and polymerase chain reaction. However, no evidence of infection could be established. A complete systemic workup to locate an endogenous source of infection was negative.
Materials and Methods An unusual posterior segment complication was identified retrospectively in two patients who had cataract extraction recently. The medical records and available fundus photographs were reviewed. Although institutional review board’s oversight was Presented at Sixth Asia Pacific Vitreoretina Society Congress, Hyderabad, India, December 1–3, 2011. None of the authors have any financial/conflicting interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.retinajournal.com). Reprint requests: Umesh C. Behera, MS, L V Prasad Eye Institute, Patia, Bhubaneswar, Odisha 751024, India; e-mail: umeshcbehera@ gmail.com
Case 2 A healthy 51-year-old woman presented with floaters and central scotoma in the left eye 2 weeks post phacoemulsification with single-piece acrylic lens implantation. She was operated for a
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Fig. 2. Fundus photograph of the left eye (Case 2) shows patchy epiretinal deposits presumed to be a result of HPMC egress into vitreous cavity through posterior capsular defect during cataract extraction.
Fig. 1. Composite fundus image of the left eye (Case 1) shows epiretinal deposits in inferior retina mimicking bacterial colonies.
posterior subcapsular cataract with a corrected vision of 20/60. Review of the operative case record revealed intraoperative posterior capsular rupture. No vitreous disturbance was documented. The viscoelastic substance used was HPMC. No prophylactic intracameral or subconjunctival antibiotic was used. The vision had improved to 20/20 postoperative. The floaters and central scotoma were gradually progressive without any associated pain in the ensuing weeks. On examination, her vision had dropped to finger counts at 1 m. There was no evidence of conjunctival injection or corneal edema. Cells (1+) in anterior chamber and a posterior capsular defect were noted on biomicroscopy. Examination of posterior segment revealed Grade 2 vitritis and multiple, patchy, white deposits on the retinal surface (Figure 2). Pars plana vitrectomy and peeling of the deposits was done to restore her vision (see Video, Supplemental Digital Content 1, http://links.lww.com/ICB/A5). The vitreous sample as well as the peeled deposits collected during vitrectomy were sent for cytology, microbial culture, and polymerase chain reaction. There was no growth of bacteria or fungi on culture. Both nested and uniplex polymerase chain reaction for bacteria and fungi was negative. Smear cytology of the peeled sample with hematoxylin and eosin staining revealed numerous histiocytes with abundant cytoplasm engulfing and surrounding the presumed HPMC deposits, representative of a granulomatous reaction (Figure 3). A complete systemic evaluation to rule out endogenous endophthalmitis turned out negative.
Discussion We report two patients with an atypical presentation of epiretinal deposits after cataract extraction where the posterior capsule barrier was breached. A similar presentation of epiretinal deposits has been described,2
where the culture of vitreous specimen had not grown any organisms. As in the previous report and in our patients, the inflammation was localized to the posterior segment without corresponding anterior segment involvement, mimicking a state of posterior segment toxic anterior segment syndrome. The presence of vitritis with white deposits on retina may represent acute postoperative endophthalmitis, but the absence of prominent anterior segment inflammation of postoperative endophthalmitis (lid edema, conjunctival congestion, corneal edema, anterior chamber fibrinous membrane/hypopyon, or ocular pain) and the negative culture and polymerase chain reaction results prompted us to suspect a toxic reaction to inadvertent viscoelastic substance egress into the vitreous cavity that spared the anterior segment from the inflammation. In our belief, if it was of infective origin, then it would have presented with a corresponding level of vitritis or anterior segment inflammation. Although the time of presentation in these two patients does not support a state of toxic anterior segment syndrome that is known to confine itself to the anterior segment and present in early postoperative period,3 the timing of a similar state in the posterior segment is not described. Use of viscoelastic substance is one of the etiological factors for toxic anterior segment syndrome. The ones in common use are HPMC and sodium hyaluronate. Hydroxypropyl methylcellulose, being a plant derivative, is not metabolized in the human body.4 Hence, an inadvertent retention in the anterior chamber after cataract extraction would complicate the postoperative period with a rise in inflammation and intraocular pressure. Although a similar behavior of HPMC in vitreous cavity is not evaluated in humans, animal studies in rabbits have demonstrated white
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membranes, and the retinal deposits were because of viscoelastic (HPMC) egress into the vitreous cavity. The distinct pattern of epiretinal distribution could be attributed to the cohesive property of HPMC. As observed in phacoanaphylactic endophthalmitis,6 these atypical presentations were presumed to be a rare inflammatory response to HPMC that occurred under special conditions, and in certain individuals, if HPMC was universally toxic to the eye, epiretinal white deposits would occur regularly after disruption of lens capsule or zonules during cataract extraction. Key words: epiretinal deposits, endophthalmitis, viscoelastic substance. Fig. 3. Photomicrograph of the smear shows sheets of histiocytes with abundant cytoplasm, some of which are seen engulfing (#) and surrounding (*) presumed HPMC deposits on retina (hematoxylin and eosin).
precipitates, vitreous bands, and inflammation.5 Sodium hyaluronate conversely being a natural biologic tissue component of vitreous does not incite an inflammatory response when in vitreous. The failure to demonstrate the presence of HPMC traces in the ocular samples on size exclusion chromatography or gas chromatography was a major limitation in this report. But based on the clinical circumstance, the cytology smear, and evidence in the literature, we presume that the vitreous inflammation,
References 1. Javey G, Albini TA, Moshfeghi AA, et al. Spectral-domain optical coherence tomography appearance of preretinal aggregation of intravitreal antibiotics. Retina 2010;30:184–185. 2. Behera UC, Shukla D, Kim R. In their patient, as in our patient, vitreous specimens were culture negative. Retina 2010;30: 1327–1328. 3. Mamalis N, Edelhauser HF, Dawson DG, et al. Toxic anterior segment syndrome. J Cataract Refract Surg 2006;32:324–333. 4. Hütz WW, Eckhardt HB, Kohnen T. Comparison of viscoelastic substances used in phacoemulsification. J Cataract Refract Surg 1996;22:955–959. 5. Koster R, Stilma JS. Comparison of vitreous replacement with Healon and with HPMC in rabbit’s eyes. Doc Ophthalmol 1986;64:13–17. 6. Marak GE Jr. Phacoanaphylactic endophthalmitis. Surv Ophthalmol 1992;36:325–339.
