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Aug 18, 2023

I wish I hadn’t done that: One in a million

This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here. Out of more than 2 million operations worldwide, there are fewer than 50 total

This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.

Out of more than 2 million operations worldwide, there are fewer than 50 total reports of endophthalmitis occurring after ICL implantation.

Surely, though, there must be at least a handful of unreported cases. And here, I am going to share with you my case of endophthalmitis after ICL implantation, which occurred after my first-ever ICL (STAAR Surgical). The operation was years ago, but I remember like it was yesterday.

The patient was a young friend of mine, a high myope, poor LASIK candidate who had been waiting for a refractive option to become available. Our practice decided to start implanting ICLs, and in the run-up, I had taken the courses, done the training and even flown across the country to visit successful practices already doing the operation.

Our practice was already well stocked with most of the equipment we thought we would need: a Pentacam (Oculus), a good biometer and a YAG laser (these were the days before the EVO ICL, so peripheral iridotomies were necessary). Before getting started, we even purchased an ArcScan, an $80,000 ultra-high-definition anterior segment ophthalmic ultrasound device, to maximize our chances of implanting the proper size ICL. We were ready to go.

My friend was excited for surgery, which we were offering at no cost because we told him he would be our first ever case. In the preoperative run-up, all the measurements were checked and checked again. His bilateral peripheral iridotomies were made (two in each eye) 2 weeks before surgery, according to protocol.

On the day of surgery, the STAAR rep was in attendance. Under their watchful eye, bilateral ICL implantation was performed with surprisingly little fanfare. Even for a neophyte, it is not a long surgery, with each eye requiring fewer than 10 minutes to complete. Although this was a case of bilateral ICL implantation, each eye was treated separately, going so far as to remove the patient from the OR back to recovery and preop again.

After the second lens was implanted, everyone was excited and relieved. We had done it! Naturally, everyone wanted to examine the operated eyes right after surgery to see these brand-new lenses. So, off to the slit lamp we went for a handful of doctors and our STAAR rep to look. Then we decided to take some pictures, so next came Pentacam and anterior segment OCT imaging. After that, it was time to check the pressure, which was elevated in the 30s mm Hg in one eye. So, we burped a paracentesis to let some fluid and perhaps retained viscoelastic out. An hour later, we rechecked the pressure, and it was still high. I burped a paracentesis again. Looking carefully, I also wondered whether the peripheral iridotomy that I had fashioned 2 weeks previously was too small, so I enlarged it slightly with our YAG laser that, after all, was sitting right there. An hour after that, we checked the pressure again, and it was fine, so satisfied all around, we sent my friend home.

The next day, vision was perfect — 20/20! — and the eyes were comfortable. We had done it! After a thoroughly self-congratulatory experience, we discharged our patient home with instructions to return in a week. But my friend did not return in a week. Instead, he called me 2 days later. Something was wrong. He could not see anything out of one eye. It was a Saturday, and I met him in the clinic. Vision in one eye was hand motions, and he had a 40% hypopyon. Nausea and panic washed over me. The other eye looked fine, but there was no denying something was horrifically wrong in one eye.

He saw a retina specialist that day; he got a tap and injection and was started on fortified topical antibiotics around the clock. My friend’s birthday trip out of state, which he was scheduled to leave for that day, was canceled. The vitreous culture grew group D streptococcus, a bug with a terrible prognosis. A week later, after an additional intravitreal antibiotic injection, my friend underwent pars plana vitrectomy in the hospital.

In the weeks and months that followed, everything was up in the air. Is the eye still infected? Do we need to remove the ICL? After literally dozens of visits between our office and the retina specialist, over the course of 9 months, the dust finally settled. The infection was gone, and the eye was quiet and comfortable with a normal pressure. The ICL had stayed in, and vision had recovered to 20/30 uncorrected, likely limited by a combination of lingering vitreous debris and early subcapsular cataract.

What went wrong? I have asked myself this question incessantly for years. We have never before or since had a case of endophthalmitis following any procedure at our facility, and of all cases, why this one? Was this dumb luck or something preventable?

Although I cannot be sure, a gray cloud of regret and despair envelops me when I consider all the postoperative futzing we did with this eye. Those many hands with their slit lamp examinations of the freshly operated eyes, the corneal and anterior segment imaging, the multiple burps of the paracentesis and, most head-scratching of all, the additional YAG laser application. All of this anxious fiddling was unwise.

Aside from “don’t touch the eyes after surgery,” I have taken a few additional lessons from this nightmare experience. First, we now inject intracameral moxifloxacin 0.05 mL at the conclusion of every ICL case. Second, we have switched our viscoelastic from OcuCoat (Bausch + Lomb) to ProVisc (Alcon) because it is easier to evacuate, and we use an actual irrigation and aspiration handpiece to remove it in an effort to reduce the likelihood of needing to burp a paracentesis after the operation. Finally, we use a 0.1% Betadine solution (one drop of 10% Betadine per 10 cc of balanced salt solution) to irrigate the surface of the eye throughout the case.

I feel fortunate to have escaped utter blinding catastrophe in this case of endophthalmitis following my first-ever ICL implantation. Besides learning not to mess with the postoperative eye, and a few tricks for the surgery itself, I have learned how important it is to stay humble and, yet, optimistic. Occasionally, our patients may yet survive and even do well, not because of but despite our efforts.