Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery

Abstract

We read with interest the case report by Villada et al.1 commenting on the overall safety of routine cataract surgery using topical anesthesia after a single case observation of severe anaphylactic reaction triggered by an intracameral antibiotic. However, we do not concur with their argument. First, the eye is an immune-privileged organ, mostly evidenced in the anterior chamber.2 The anaphylactic reaction observed in this patient must have been the result of presentation of the culprit antibiotic molecules to the antigen-presenting cells within the bloodstream, triggering immunoglobulin E–mediated type-I hypersensitivity.3 Conceptually speaking, intracameral antibiotic administration in a patient with a history of antibiotic allergy is highly akin to the direct intravenous route of administration in terms of bioavailability, particularly in the face of a disrupted blood–aqueous barrier during phacoemulsification. Occurrence of anaphylactic reaction in this circumstance is not as unexpected as that supposed by the authors. The idiosyncrasy of intraocular delivery of immunogen has nothing to do with most of the standard steps of topical anesthesia cataract surgery. Second, nowadays, topical anesthesia cataract surgery is largely practiced without the addition of an intracameral antibiotic.3 Even in cases with intracameral antibiotic injection, Ragusa et al.4 have indicated, using a retrospective review of 2206 participants, that the risk for systemic anaphylaxis is as low as 0.06%. Understanding the standard art of practice in topical anesthesia cataract surgery, the pharmacokinetics of intracameral antibiotics, and the risk for systemic anaphylaxis may make the authors' generalization dubious.