Comment on hydration with Cefuroxime-a method for sealing a small leaking corneal perforation

Dear Editor,

In a recent interventional case report, Allon et al[1] hydrated corneal stroma with cefuroxime to seal a small traumatic leaky corneal perforation that was unresponsive to prior soft bandage contact lens application for 6d.

We would like to just remind the possible complications of intracameral cefuroxime in eyes with already compromised cornea. High doses of cefuroxime induced ocular anterior or posterior segment inflammation at short-term has been reported[2]. Macular edema and serous macular detachment have also been documented after intracameral injection of moderately elevated[3] as well as standard dose of cefuroxime[4].Long-term clinical effects of the drug are not known in detail yet.

Cefuroxime is one of the most common free radical inducing intracameral surgical preparations together with phenylephrine during phacoemulsification[5]. Intracameral cefuroxime significantly altered oxidative stress parameters when compared to intracameral vancomycin in the corneal tissue during the anterior segment surgery[6].

It has been previously proposed that stromal hydration of cefuroxime may exacerbate edema and inflammation in the cornea that is already compromised by phacoemulsification.Corneal inflammation may generalize and this situation probably triggers retinal inf l ammation and edema[4].

Taking into account that traumatic corneal perforation is an inflammatory process, sealing of corneal stroma with cefuroxime would further traumatize the cornea if it was performed during the acute phase. Although they suggested earlier intervention with cefuroxime, it seems that Allon et al[1]actually did the best thing by waiting 6d during which the acute inf l ammation probably subsided. We think earlier stromal and intracameral cefuroxime delivery would have deteriorated the condition of already acutely inf l amed and vulnerable cornea.

ACKNOWLEDGEMENTS

Conflicts of Interest: Aslankurt M, None; Çekiç O, None.

REFERENCES

1 Allon G, Beiran I, Blumenthal EZ. Hydration with Cefuroxime-a method for sealing a small leaking corneal perforation. Int J Ophthalmol 2016;9(5):792-793.

2 Delyfer MN, Rougier MB, Leoni S, Zhang Q, Dalbon F, Colin J,Korobelnik JF. Ocular toxicity after intracameral injection of very high doses of cefuroxime during cataract surgery. J Cataract Refract Surgery 2011;37(2):271-278.

3 Wong DC, Waxman MD, Herrington LJ, Shorstein NH. Transient macular edema after intracameral injection of moderertely elevated dose of cefuroxime during phacoemulsfication surgery. JAMA Ophthalmol 2015;133(10):1194-1197.

4 Aslankurt M, Çekiç O, Andı İ, Dursun O. Transient macular edema after standard dose of intracameral cefuroxime injection during phacoemulsif ication. Can J Ophthalmol 2016;51(5):e141-e142.

5 Lockington D, Macdonald ECA, Young D, Stewart P, Caslake M, Ramaesh K. Presence of free radicals in intracameral agents commonly used during cataract surgery. Br J Ophthalmol 2010;94(4):525-526.

6 Özlem TY, Necati DM, Fatma YM, Gülsen Y, Ayşe NB, Firdevs Ö. Are cefuroxime and vancomycin really safe on the corneal endothelial cells?Graefes Arch Clin Exp Ophthalmol 2010;248(3):415-420.

Author Reply to the Editor Dear Editor,

We thank Aslankurt et al for their thoughtful comment.Indeed, there are possible complications of intrastromal and intracameral injection of cefuroxime to eyes with compromised cornea. Possible complications include:inf l ammation[1], macular edema, serous macular detachment[2-3],changes in oxidative stress and corneal edema[4]. The long-term effect of the drug is also not fully known. Vancomycin might be somewhat safer, but more research is needed to determine this[5].

Despite the risks mentioned above, the intracameral injection of cefuroxime at the conclusion of cataract surgery is considered safe, complications are rare, and injection is associated with a lower risk of post-operative endophthalmitis[6]. Furthermore,traumatic corneal perforation is much more likely to be infected and to lead to endophthalmitis than sterile cataract surgery, and hence the application of antibiotic is far more important in this case[7].

We agree that use of bandage contact lens with aqueous suppressant is safer for the cornea, yet does not protect against endophthalmitis. Very large perforations should be treated with methods like suturing or application of tissue adhesives, since hydration is unlikely to seal the leak.

REFERENCES

1 Delyfer MN, Rougier MB, Leoni S, Zhang Q, Dalbon F, Colin J,Korobelnik JF. Ocular toxicityafter intracameral injection of very high doses of cefuroxime during cataract surgery. J Cataract Refract Surg 2011;37(2):271-278.

2 Wong DC, Waxman MD, Herrington LJ, Shorstein NH. Transient macular edema after intracameral injection of a moderertely elevated dose of cefuroxime during phacoemulsification surgery. JAMA Ophthalmol 2015;133(10):1194-1197.

3 Aslankurt M, Çekiç O, Andı İ, Dursun O. Transient macular edema after standard dose of intracameral cefuroxime injection during

phacoemulsif i cation. Can J Ophthalmol 2016;51(5):e141-e142.

4 Lockington D, Macdonald ECA, Young D, Stewart P, Caslake M,Ramaesh K. Presence of free radicals in intracameral agents commonly used during cataract surgery. Br J Ophthalmol 2010;94:1674-1677.

5 Özlem TY, Necati DM, Fatma YM, Gülsen Y, Ayşe NB, Firdevs Ö. Are cefuroxime and vancomycin really safe on the corneal endothelial cells?Graefes Arch ClinExp Ophthalmol 2010;248(3):415-420.

6 Daien V, Papinaud L, Gillies MC, Domerg C, Nagot N, Lacombe S, Daures JP, Carriere I, Villain M. Effectiveness and safety of an intracameral injection of cefuroxime for the prevention of endophthalmitis after cataract surgery with or without perioperative capsular rupture.JAMA Ophthalmol 2016;134(7):810-816.

7 Allon G, Beiran I, Blumenthal EZ. Hydration with Cefuroxime-a method for sealing a small leaking corneal perforation. Int J Ophthalmol 2016;9(5):792-793.

Gilad Allon, ItzchakBeiran, Eytan Z. Blumenthal

Department of Ophthalmology

Rambam Health Care Campus

Haifa 3109601, Israel