Structural and Functional Insight into Intracameral Cefuroxime Ocular Toxic Syndrome (ICOTS) in Eyes with Disrupted Intraocular Barrier

Abstract

Intracameral cefuroxime is commonly used as a prophylaxis against endophthalmitis following cataract surgery. While its effectiveness is well-documented, concerns remain regarding potential toxicity. Intracameral cefuroxime ocular toxic syndrome (ICOTS) is characterized by acute, extensive, and serous retinal detachment that usually resolves spontaneously. However, the long-term effects of ICOTS have not yet been studied. This study aims to provide new insights into ICOTS using multimodal imaging, retinal electrophysiology, and perimetry to assess both acute and chronic functional and structural changes in eyes with a disrupted intraocular vitreous barrier. This retrospective case series included four patients affected by ICOTS who underwent cataract surgery with standard-dose intracameral cefuroxime (1.0 mg/0.1 ml). Three patients had previously undergone pars-plana vitrectomy and one patient had undergone anterior vitrectomy. Patients were followed up to 1 year after surgery. Evaluations included optical coherence tomography (OCT), ultra-wide-field (UWF) OCT-angiography (OCTA), automated perimetry, and multifocal electroretinography (ERG) at the preoperative visit (T0) and at 1 day (T1), 1 week (T2), 1 month (T3), 6 months (T4), and 1 year (T5) after cataract surgery. At T1, all patients had acute extensive serous retinal detachments. UWF-OCTA revealed increased superficial vessel density during the acute phase, with only partial restoration at follow-up. Two cases had permanent structural damage to the outer retina. Functional assessments showed transient changes in multifocal ERG responses, returning to near-normal levels within T3. Best-corrected visual acuity worsened at T1 and improved after the subretinal fluid resolution (T2). Intracameral cefuroxime ocular toxic syndrome may induce persistent retinal changes despite fluid resolution in eyes with a disrupted intraocular barrier due to prior vitrectomy. Early OCT assessment can help to identify this condition. Further investigation, incorporating UWF-OCTA and ERG for a comprehensive assessment of ICOTS, along with revised informed consent protocols for patients undergoing cataract surgery with this antibiotic prophylaxis, may be indicated when risk factors are identified. Cataract surgery is one of the most common procedures worldwide. To prevent infection after surgery, ophthalmologists often inject an antibiotic called cefuroxime into the eye. While this method effectively reduces the risk of serious eye infections, it can also lead to ocular toxicity, potentially causing temporary or even permanent damage to the retina. In this study, we examined four patients who developed fluid accumulation under the retina after receiving cefuroxime during cataract surgery. These patients had a weakened intraocular barrier due to previous surgery or intraoperative complications. The day after cataract surgery, all patients complained of blurred vision due to acute retina toxicity. Although the retinal fluid disappeared after 1 week, advanced imaging and functional techniques performed up to 1 year indicated that these patients experienced long-term changes in their retina, including decreased blood flow and permanent structural alterations. Our findings suggest that patients with a disrupted intraocular barrier may be at a higher risk of developing this toxicity. Ophthalmologists should consider this risk when choosing antibiotics for infection prevention and should also inform patients about the potential of ocular toxicity. Early detection with optical coherence tomography and careful patient monitoring can help manage this complication.

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