Acute Post–operative Endophthalmitis Associated with Trypan Blue During Cataract Surgery

Abstract

Purpose: : Endophthalmitis is a rare, but often devastating complication of cataract surgery. In 2005, the FDA released a recall of specific lots of Trypan Blue 0.06% Ophthalmic Solution, a dye used to enhance visualization of the anterior lens capsule during cataract surgery, because of possible contamination with Pseudomonas aeruginosa. We describe the aggressive clinical presentation and postoperative outcome of two cases of severe hyper–acute Pseudomonas endophthalmitis associated with intra–operative use of Trypan Blue.

Methods: : Case reports of two patients who presented with post–operative Pseudomonas endophthalmitis after undergoing cataract surgery at a large teaching hospital approximately 8 months prior to the Trypan Blue recall.

Results: : In Case 1, an 82 year–old male, with best–corrected pre–operative visual acuity of "counting fingers," underwent uncomplicated cataract surgery for a dense nuclear sclerotic cataract of his right eye. Thirty–two days later, Case 2, a 73 year–old male, with best–corrected pre–operative visual acuity of 20/40, underwent uncomplicated cataract surgery for a cortical cataract of his left eye. In each case, Trypan Blue was injected intracamerally, using standard technique, prior to initiation of the capsulorrhexis procedure. Cases 1 and 2 presented on post–operatve days 2 and 1, respectively, with pain, redness, decreased vision, and examination findings consistent with endophthalmitis. Initially, both cases were administered immediate intra–vitreal antibiotic injections. Due to rapid deterioration of vision and aggressive progression of intraocular inflammatory reaction, both eyes subsequently underwent vitrectomy surgery. Final post–operative visual acuities for Cases 1 and 2 were "hand motion" and 20/80, respectively. Cultures from both cases grew Pseudomonas aeruginosa, an organism rarely associated with acute post–operative endophthalmitis. Trypan Blue aliquots used in both cases were from the same batch, obtained from the compounding pharmacy that subsequently issued the recall in the United States.

Conclusions: : Pseudomonas contaminated Trypan Blue may result in an unusually aggressive, hyper–acute post–operative endophthalmitis. Knowledge of the clinical presentation of this condition is important for cataract surgeons to make cogent decisions regarding the care of these patients.

Keywords: endophthalmitis • cataract