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 Table of Contents  
Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 96-98

Stevens–Johnson syndrome following cataract surgery

1 Department of Ophthalmology, Chang Gung Memorial Hospital, Chia-Yi; College of Medicine, Chang Gung University, Kwei Shan, Tao-Yuan, Taiwan
2 College of Medicine, Chang Gung University, Kwei Shan, Tao-Yuan, Taiwan
3 Ai-Lin Clinic, San-Shia Area, Taipei, Taiwan

Date of Web Publication10-Jun-2015

Correspondence Address:
Li-Ju Lai
Department of Ophthalmology, Chang Gang Memorial Hospital, Number 6, West section, Chia-Puz Road, Puzi City, Chiayi County 61363
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.tjo.2014.05.005

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A case of Stevens–Johnson syndrome in a healthy 58-year-old woman who underwent cataract surgery under topical anesthesia is reported. General skin erosions developed 2 hours after surgery. The patient’s family doctor diagnosed that she was allergic to seafood. One month later, she underwent phacoemul-sification surgery in the other eye. After surgery, she developed Stevens–Johnson syndrome with general skin lesions, erythema nodosa, genital mucosa erosion, oral ulcers, gastritis, and conjunctiva edema. The symptoms subsided 2 weeks later after immunotherapy. Although nonpreserved anesthesia (2% lido-caine) has seldom been reported to cause allergic reactions via the intravenous or the intramuscular route, it is possible that an intracameral injection of 0.2% lidocaine during cataract surgery can induce Stevens–Johnson syndrome. Careful evaluation of the patient’s history and proper treatment were recommended to prevent additional complications.

Keywords: allergic reaction, cataract surgery, lidocaine, phacoemulsification, Stevens–Johnson syndrome

How to cite this article:
Wu SH, Shen JH, Hsu WH, Lin CW, Lai LJ. Stevens–Johnson syndrome following cataract surgery. Taiwan J Ophthalmol 2015;5:96-8

How to cite this URL:
Wu SH, Shen JH, Hsu WH, Lin CW, Lai LJ. Stevens–Johnson syndrome following cataract surgery. Taiwan J Ophthalmol [serial online] 2015 [cited 2023 Mar 25];5:96-8. Available from: https://www.e-tjo.org/text.asp?2015/5/2/96/204162

  1. Introduction Top

Intracameral lidocaine, used as a local anesthetic for phaco-emulsification, is now a standard procedure and widely used for cataract surgery.[1],[2] Lidocaine hydrochloride, an amide-type local anesthetic, is commonly used for facial plastic procedures.[1] Although lidocaine is frequently used during these procedures, adverse drug reactions could still happen, such as hypotension, bradycardia, urticaria, tissue necrosis, and angioedema, even administered in a very small dose [Table 1]. [2] Moreover, most of the reported reactions are caused by hypersensitivity. In the case of anaphylactic reaction to lidocaine, early treatment with epineph-rine, oxygenation, and intravenous fluid resuscitation resulted in relief of the symptoms. [3]
Table 1: Adverse drug reactions caused by lidocaine hydrochloride.

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Stevens–Johnson syndrome is an acute, self-limiting disorder which affects the skin and two or more mucosal membranes.[4] With the exception of certain idiopathic cases, Stevens–Johnson syndrome is usually triggered by medications or associated with infections.[5] In this report, we present one patient who developed Stevens–Johnson syndrome which was induced by intracameral administration of lidocaine during phacoemulsification.

  2. Case Report Top

A 58-year-old woman underwent phacoemulsification under topical anesthesia. Perioperative medications included topical eye medications: 0.5% proparacaine hydrochloride (Alcaine; S.A. Alcon-Couvreur N.V., Puurs, Belgium), 1% tropicamide (Mydiracyl 5%; Alcon-Couvreur), 10% phenylephrine hydrochloride (Wu-Fu, I-Lan County, Taiwan), and levofloxacin 0.5% (Cravit; Santen, Pharmaceutical Co., Ltd., Osaka, Japan). The patient received an intra-cameral injection of 0.04 mg (0.2 mL, 2% xylocaine, diluted with 0.8 mL balanced salt solution [BSS]) preservative-free lidocaine hydrochloride (2% xylocaine; AstraZeneca Taiwan, Taipei, Taiwan). Additionally, fluorometholone 1% (1 mg/mL) (FML; Sinphar Pharmaceutical Co., Dongshan Township, I-Lan County, Taiwan) and levofloxacin were both applied BID for 2 weeks. The patient developed a generalized skin rash with itching 2 hours after cataract surgery. An antihistamine (diphenhydramine (Vena, Panbiotic labortories, Kaohsiung City, Taiwan) [1 ampoule]) and a steroid (dexamethasone [8 mg], Standard Chem. & Pharm. Co., Ltd., Tainan City, Taiwan, intravenous [IV] push) were prescribed, and the symptoms resolved 5 days later. The oral mucosa, conjunctiva, and genital mucosa were all intact. Vision in the right eye was 20/20 with minimal signs of inflammation.

One month later, the patient underwent surgery in the other eye with the same procedures and medications. Immediately after the surgery, she developed a diffuse, erythematous, pruritic full-body rash that involved the palms of her hands and the soles of her feet. She also had fever and chest tightness. The patient’s eyelids were edematous and the conjunctiva were chemotic. Antihistamine (diphenhydramine HCl 30 mg/L ampoule) and steroid injections (dexamethasone [8 mg], IV push) had only a minimal effect. Two days later, the skin lesion progressed to erythema nodosa along with other symptoms, such as genital mucosa erosion, oral ulcers, and gastritis. As we suspected an adverse drug reaction related to the patient’s cataract surgery, she was referred to an immunologist (Dr C.-W. Lin). Immunotherapy was arranged immediately. Venous blood (1 mL) was drawn and fully mixed with 1 mL of 2% lidocaine, which was intramuscularly injected slowly back into the patient. Ascorbic acid (200 mg/tab, TID) and prednisolone (5 mg/tab, BID) were prescribed. The itching and burning sensation subsided 2 days after the first injection. The immunotherapy was performed twice a week and continued for 3 weeks, until the skin lesions had resolved. Vision in both eyes was 20/20, and the patient’s ocular examinations were uneventful during this period.

  3. Discussion Top

To the best of our knowledge, this is the first published report of Stevens–Johnson syndrome after phacoemulsification. To determine the causative agent, we reviewed the patient's medical history throughout the event. The topical eye medications, which included 0.5% proparacaine hydrochloride,1% tropicamide, and 10% phenylephrine hydrochloride had been used before surgery for the posterior chamber intraocular lens (PC-IOL) power calculation. Levofloxacin and fluorometholone 0.1% had been prescribed and administered after the first operation. As no adverse effect had occurred during these two periods, we could exclude the abovementioned medications. Intracamerally injected lidocaine during the surgery was the only drug which could have induced this adverse reaction.

Intracameral injection of preservative-free lidocaine is widely used for local anesthesia and discomfort relief in cataract surgery with minimal inflammation and endothelial cell loss.[1],[4],[7] The medication normally provides persistent, stable, and satisfactory pupil dilation for a safe phacoemulsification and intraocular lens implantation in most patients.[1],[2] However, it may lead to rare but serious adverse drug reactions, such as Stevens–Johnson syndrome. In this report, the patient suffered from a skin lesion which progressed to erythema nodosa along with genital mucosa erosion, oral ulcers, and gastritis.[8]

Stevens–Johnson syndrome is predominantly known as a drug-induced disease which causes severe adverse cutaneous reactions which predominantly involve the skin and mucous membranes, and is considered a medical emergency as it is potentially fatal.[9],[10],[11] The reactions, which are characterized by extensive necrosis and detachment of the epidermis, are followed by erosions of the skin and mucous membranes. The most common causative medications are sulfonamides, nonsteroidal antiinflammatory drugs, anticonvulsants, and allopurinol [Table 2].[10],[11],[12],[14] The mainstays of therapy are specialized supportive care, discontinuation of the use of the suspected inducing drug, and use of intravenous steroid therapy as the main treatment regimen.[10],[11],[12],[13] Moreover, in a small series of patients, immunomodulating agents such as high-dose intravenous immunoglobulin therapy is effective.[12]
Table 2: Common etiologic drugs in Stevens–Johnson syndrome.

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Supportive management still remains the mainstay of the treatment for Stevens–Johnson syndrome.[8] This involves a skilled clinical assessment, an early identification of the etiology, and an immediate withdrawal of the causative drug. Close monitoring of fluids and electrolytes is also important for preventing additional complications.[9],[10],[11],[12] In this case, we also used immunotherapy immediately. Venous blood (1 mL) from the patient was fully mixed with 1 mL of 2% lidocaine, which was slowly administered by intramuscular injection. This method was performed twice a week and continued for 3 weeks, and the cutaneous lesions and visual acuity showed obvious improvement after treatment. In this case report, we provided this safe and easy method to treat this severe adverse drug reaction.

In conclusion, an intracameral injection of lidocaine, widely used in phacoemulsification, can cause adverse drug reactions. Definitive treatment includes prompt identification and discontinuation of the possible causative medication, as well as appropriate supportive measures. Proper immunotherapy can prevent further steroid complications and treat the symptoms efficiently. Ophthalmologists who perform cataract surgery should be aware of this adverse drug reaction and be familiar with its treatment.

Conflicts of interest: The authors do not have any proprietary or commercial interests related to the manuscript. No funding was received for the work described in this manuscript.

  References Top

Ezra DG, Allan BD. Topical anaesthesia alone versus topical anaesthesia with intracameral lidocaine for phacoemulsification. Cochrane Database Syst Rev. 2007;18:CD005276.  Back to cited text no. 1
Irle S, Luckefahr MH, Tomalla M. Topical anesthesia as routine procedure in cataract surgery–evaluation of pain and complications in 1010 cases. Klin Monbl Augenheilkd. 2005;222:36–40.  Back to cited text no. 2
Kennedy KS, Cave RH. Anaphylactic reaction to lidocaine. Arch Otolaryngol Head NeckSurg. 1986;112:671–673. Yu, Tais Hitomi Wakamatsu, Ana Luisa Hofling-Lima. Evaluation of conjunctival bacterial flora in patients with Stevens–Johnson Syndrome. Clinics (Sao Paulo). 2014;69:168–172.  Back to cited text no. 3
Bonnet MC, du Cailar G, Deschodt J. Anaphylaxis caused by lidocaine. Ann Fr Anesth Reanim. 1989;8:127–129.  Back to cited text no. 4
Sharwood PL, Thomas D, Roberts TV. Adverse medical events associated with cataract surgery performed under topical anaesthesia. Clin Experiment Ophthalmol. 2008;36:842–846.  Back to cited text no. 5
Luciana Frizon, Marília Cavalcante Araújo, Larissa Andrade, Maria Cecília Zorat Yu, Tais Hitomi Wakamatsu, Ana Luisa H€ofling-Lima. Evaluation of conjunctivalbacterial flora in patients with Stevens–Johnson Syndrome. Clinics (Sao Paulo). 2014;69:168–172.  Back to cited text no. 6
Tan CS, Fam HB, Heng WJ, Lee HM, Saw SM, Au Eong KG. Analgesic effect of supplemental intracameral lidocaine during phacoemulsification under topical anaesthesia: a randomized controlled trial. Br J Ophthalmol. 2011;95:837–841.  Back to cited text no. 7
Roujeau JC, Kelly JP, Naldi L, Rzany B, Stern RS, Anderson T, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333:1600–1607.  Back to cited text no. 8
Halevy S. Stevens-Johnson syndrome and toxic epidermal necrolysis–updates and innovations. Harefuah. 2010;149:186–190.  Back to cited text no. 9
Julie Papay, Nancy Yuen, Greg Powell, Maja Mockenhaupt, Thomas Bogenrieder. Spontaneous adverse event reports of Stevens-Johnson syndrome/toxic epidermal necrolysis: detecting associations with medications. Pharmacoepide-miolDrugSaf. 2012;21:289–296.  Back to cited text no. 10
Hye-In Kim, Shin-Woo Kim, Ga-Young Park, Eu-Gene Kwon, Hyo-Hoon Kim, Ju-Young Jeong. Causes and treatment outcomes of Stevens-Johnson syndrome and toxic epidermal necrolysis in 82 adult patients. Korean J Intern Med. 2012;27:203–210.  Back to cited text no. 11
Harr T, French LE. Toxic epidermal necrolysis and Stevens-Johnson syndrome. Orphanet J Rare Dis. 2010;5:39.  Back to cited text no. 12
Fritsch PO, Sidoroff A. Drug-induced Stevens-Johnson syndrome/toxic epidermal necrolysis. Am JClin Dermatol. 2000;1:349–360.  Back to cited text no. 13


  [Table 1], [Table 2]


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1. Introduction
2. Case Report
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