Case Report: Maculopathy following standard dose intracameral cefuroxime injection during ICL surgery

To describe two rare occurrences of acute toxic maculopathy, specifically Intracameral Cefuroxime Ocular Toxic Syndrome (ICOTS), following uncomplicated posterior-chamber toric phakic implantable collamer lens (TICL) surgery despite the administration of a standard dosage of cefuroxime.

This case report identified two patients from a clinical volume of 1,590 eyes treated between 2021 and 2024. Inclusion criteria consisted of patients undergoing bilateral TICL implantation with intracameral cefuroxime who presented with unexpected visual disturbances on postoperative day 1. To isolate cefuroxime as the primary toxic factor, exclusion criteria included systemic comorbidities (such as diabetes mellitus), pre-existing ocular pathologies (including uveitis, macular degeneration, or prior retinal detachment), history of prostaglandin analog use, or baseline structural abnormalities on preoperative optical coherence tomography (OCT). Clinical evaluation included UDVA, BCVA, and SD-OCT imaging.

Two female patients (aged 29 and 32) underwent bilateral TICL surgery with 0.1 mL of 10 g/L intracameral cefuroxime administered at the conclusion of the procedure. On postoperative day 1, both patients presented with unilateral vision loss (BCVA 20/32 and 20/80, respectively) and reported dim or distorted vision. SD-OCT revealed macular edema and subretinal fluid (SRF). Following conventional postoperative treatment with topical steroids and nonsteroidal anti-inflammatory drugs, complete absorption of SRF was achieved within two weeks to one month, and BCVA improved to 20/16 and 20/20, respectively.

While intracameral cefuroxime is a highly effective prophylactic against endophthalmitis, it may cause sporadic toxic maculopathy even at standard doses during ICL surgery. Unlike typical post-cataract inflammatory edema, ICOTS presents acutely on day 1. Surgeons should maintain a high index of suspicion and utilize early OCT imaging for unexpected postoperative visual disturbances.