Comment on: Intraocular ointment after phacoemulsification

We read with interest the paper by Qin and Liu on intraocular ointment after phacoemulsification.1 The authors described a patient with retinitis pigmentosa who underwent uneventful phacoemulsification in the right eye, through a self-sealing 3.0 mm clear corneal incision. Although no wound leakage was observed at the conclusion of the procedure, the patient exhibited an oil droplet-like substance in the anterior chamber week 1 postoperatively, likely related to the antibiotic/steroid ointment prescribed after surgery. Six months later, the eye developed redness and pain in association with significant decrease in visual acuity; a mobile sphere was still visible in the anterior chamber. The authors noted that previous cases of intraocular ointment have shown no significant clinical effects, but given the typically milder anterior chamber and vitreous inflammation in patients with retinitis pigmentosa, early surgical intervention to remove retained ointment is crucial to prevent further complications. In 2006, we reported clinical and laboratory findings of 8 cases of toxic anterior segment syndrome (TASS) related to an oily substance in the anterior chamber of eyes after uneventful phacoemulsification with intraocular lens (IOL) implantation performed by the same surgeon through clear corneal incisions.2 Postoperative medications included antibiotic/steroid ointment and pilocarpine gel; each eye was firmly patched at the end of the procedure. On day 1, some patients presented with diffuse corneal edema, increased intraocular pressure (IOP), and an oily film-like material within the anterior chamber coating the corneal endothelium. The others presented with an oily bubble floating inside the anterior chamber (Figure 1). Additional surgical procedures required in this series included penetrating keratoplasty, IOL explantation, and trabeculectomy. Two corneal buttons analyzed histopathologically showed variable thinning of the epithelium with edema, a diffusely thickened stroma, and absence of the endothelial cell layer.Figure 1.: Slitlamp clinical photograph taken during the first postoperative week showing a large bubble floating into the anterior chamber.Later, we described the case of a patient who started to have recurrent episodes of anterior chamber inflammatory reaction, 8 months after uneventful phacoemulsification with IOL implantation.3 Postoperative medications in that case included antibiotic/steroid drops and ointments. Analysis of the explanted lens in that case showed the presence of compounds commonly found in the vehicle of ophthalmic ointments. McDonnell et al. evaluated the dynamics of clear corneal incisions in eyes obtained postmortem.4 Optical coherence tomography was used to image corneal incisions in real time as the IOP in the eyes was varied with an infusion cannula showing that, at low pressures, wound edges tended to gape, starting at the internal aspect of the wound. Shingleton et al. demonstrated that a significant percentage of eyes having clear corneal phacoemulsification had an IOP of 5 mm Hg or less 30 minutes postoperatively.5 Patients included in the above-mentioned studies from our group did not have any particular associated ocular condition. Considering that TASS can potentially occur if ointment gains intraocular access, in our opinion, postoperative drops should be preferred after surgery; furthermore, any intraocular ointment should be irrigated from the eye as soon as observed, regardless if the patient has or not associated conditions such as retinitis pigmentosa.