Instrument debris-related fibrinous uveitis after pediatric cataract surgery

Abstract

Dear Editor, Retained foreign matter introduced perioperatively is believed to play a causative role in postoperative intraocular inflammation in uncomplicated surgery.[1] Processed reusable ophthalmic instruments, and particularly lens introducers, have been shown to retain debris such as denatured viscoelastic and are a major source of retained foreign matter.[2] We present a case of postoperative fibrinous anterior uveitis presumed secondary to debris transferred from the lens introducer onto the intraocular lens implant (IOL). A 9-year-old boy underwent uncomplicated cataract surgery for juvenile cataract associated with hypoparathyroidism-related-hypocalcemia. Left-sided surgery was performed first, and an AcrySof MA60AC (22 Dioptre) standard lens was inserted. The child had an uneventful postoperative recovery. Right eye cataract surgery was done a month later, and an AcrySof SN60WF (24 Dioptre) lens (blue light filter IOL) was implanted due to a change in the model of IOL used by the hospital. Both IOLs were folded and then inserted using John Weiss lens introducer (model number 0109163). Two weeks post-right cataract surgery, despite excellent compliance, the patient developed photophobia and ache in the right eye during tapering of topical steroids. When he presented, his right visual acuity was reduced to 20/40 (from 20/25 one week postoperatively). Slit lamp examination revealed anterior uveitis and fibrin deposits closely related to crystalline debris seen on the anterior surface of the IOL [Fig. 1]. The debris was noted to be in the configuration of the contact surfaces of the lens introducer used during surgery. The fibrinous anterior uveitis was treated aggressively with topical steroids (1% prednisolone acetate) and resolved completely within three weeks. The debris marks on the IOL persisted without causing any further effects. No uveitis or debris was noted in the left eye. Figure 1 Slit lamp photograph of the anterior segment of the right eye showing crystalline debris transferred from lens folder onto the anterior surface of the IOL with surrounding secondary fibrinous uveitis We believe the debris on the IOL played a causative role in the postoperative fibrinous uveitis in this patient. Although causality is not certain, the alignment of the fibrin strands to the debris strongly suggests this. The delay in presentation may have been due to partial treatment of the inflammation by the tapering postoperative topical steroids. A potential confounding factor is that the patient received a tinted IOL in the right eye only. Beauchamp et al. demonstrated a higher rate of postoperative inflammation observed in pediatric eyes, which received the tinted AcrySof SN60AT IOL in comparison to non-tinted AcrySof SA60AT IOL.[3] However, this is unlikely to explain our findings as the localized fibrin deposits on the IOL indicated a focal inflammatory trigger and not a generalized one such as a tint chromophore. This case highlights the issue of retained foreign matter on processed ophthalmic instruments, which could precipitate vigorous post-operative inflammation, if deposited intraocularly. We support the suggestion of Dinakaran et al. that instruments are inspected under the microscope by the surgeon prior to use, and that special attention must be paid to contact surfaces.