Cataract surgery during active methicillin-resistant Staphylococcus aureus infection
A 71-year-old retired lawyer who was a known diabetic, hypertensive, heavy smoker with coronary artery disease, renal failure, and benign prostate hypertrophy (on tamsulosin) had a chronically infected sternal wound with an indwelling catheter after coronary artery bypass surgery 6 months before presentation to the eye clinic. Repeated medical attempts at sterilizing the sternal wound failed, with accompanying irreversible antibiotic nephropathy. He presented with severe visual loss to counting fingers with dense nuclear sclerosis and posterior subcapsular cataract bilaterally. The patient accepted the risks of postoperative infection as previously detailed by the infectious diseases team. The patient underwent phacoemulsification of the right eye under topical anesthesia with xylocaine gel and without instillation of topical povidone iodine (because of dry eye, risk of epithelial toxicity, and loss of clarity during surgery)., Special attention was paid to creating elongated, three-plane, self-sealing limbal tracts. The patient did not receive intracameral antibiotics or oral antibiotics because of recent antibiotic nephrotoxicity. The eye patch was placed for 1 hour and removed to allow topical therapy. He was put on topical moxifloxacin and a combination of netilmicin sulfate 0.3% with dexamethasone phosphate 0.1% drops. The drops were administered hourly on the day of surgery with taper thereafter, as in the first case. Vision in the right eye recovered to 6/6. One month later, the patient underwent phacoemulsification of the left eye with 4.5 mm anterior capsulorhexis. The foldable implant was placed in the bag under balanced salt irrigation. Excess pressure was exerted at 6 o’clock (in order to engage the superior haptic) in a thinned out capsular bag, leading to localized capsular rupture with no vitreous loss. The implant was centered intraoperatively and slowly started decentering inferiorly. He received the same topical regimen as for the right eye. Two months later, a secondary anterior chamber intraocular lens was implanted with the help of viscoelastic material (under topical anesthesia with xylocaine gel and without topical povidone iodine). Upon aspiration of the viscoelastic material, no vitreous was noted in the anterior chamber. Suturing of the three-plane, temporal 6 mm limbal incision was done with 10-0 nylon, ensuring a tight wound. The same regimen of topical drops allowed good visual recovery with no signs of inflammation on close observation (examination every 2 days) in the early postoperative period. Six weeks after the last surgery, uncorrected visual acuity was 6/12 in the left eye.