Sir,

Wound infection is a rare postoperative complication after cataract extraction.1, 2, 3 Although clear corneal phacoemulsification is commonly performed, there is limited information in the literature on clear corneal wound infections after phacoemulsification.3, 4 Previous reported cases of clear corneal wound infection after phacoemulsification occurred at least 4 days after surgery.3 We report a patient who developed corneal wound infection as early as 2 days after temporal clear corneal phacoemulsification.

Case report

A 73-year-old female underwent uneventful right topical temporal sutureless clear corneal phacoemulsification in November 2003. She had a history of diabetes mellitus with good glycaemic control and there was no evidence of blepharitis preoperatively. Examination day 1 postoperatively was unremarkable and the wound was self-sealing without leakage. She was given gutt 1% prednisolone acetate and gutt 0.5% chloramphenicol four times daily. On the following day, she returned with increased right eye redness and pain and her visual acuity was 6/30. Slit-lamp examination showed a dense corneal infiltrate at the temporal corneal wound with 4+ cells in the anterior chamber and a 0.5 mm hypopyon (Figure 1). She was hospitalised and treated with fortified gentamycin 15 mg/ml and fortified vancomycin 50 mg/ml hourly. Culture of the corneal wound grew Staphylococcus aureus sensitive to gentamycin, fusidic acid, and cloxacillin. The hypopyon resolved 1 week after treatment and the antibiotics were gradually tapered. At 8 weeks after treatment, the wound infiltrate resolved completely and became a scar. Her best-corrected visual acuity for the right eye 10 months postoperatively was 6/9. The corneal scar resulted in mild against-the-rule astigmatism with a final refraction of +0.50DS/−1.50DC × 85.

Figure 1
figure 1

Slit-lamp examination of the right eye 2 days after sutureless temporal clear corneal phacoemulsification showing a corneal abscess and dense infiltrate at the temporal clear corneal wound with severe inflammation and hypopyon in the anterior chamber.

Full size image

Comment

Clear corneal phacoemulsification is commonly performed but the incidence of wound infection is rare. Cosar et al3 reported seven patients with clear corneal wound infections after phacoemulsification. In the series, four of the five cases with cultures performed yielded Gram-positive organisms which included two cases of methicillin-resistant S. aureus (MRSA). The median onset of signs and symptoms in these patients was 10 days postoperatively, with a range of 4–60 days. Chiang et al4 also reported a patient who developed MRSA wound ulcer 2 weeks after clear corneal phacoemulsification. In our patient, the corneal abscess with hypopyon developed acutely between day 1 and 2 postoperatively. This suggested that postoperative wound infection after phacoemulsification may develop very rapidly, especially after infection due to aggressive microorganism like S. aureus. Fortunately, the organism was sensitive to commonly used antibiotics and she developed good response after prompt treatment. Our case highlighted the importance of informing patients to return immediately when new symptoms arise postoperatively.

Risk factors for the development of wound infection in our patient included diabetes and temporal corneal wound with the lack of wound coverage by the upper eyelid. A previous study on endophthalmitis after phacoemulsification has demonstrated that temporal corneal incisions may lead to increased risk of postoperative endophthalmitis compared with superior corneal incisions.5 Cataract surgeons may therefore consider using superior corneal wound in patients at high risk for wound infection.