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Editor,—Adverse reactions associated with the topical administration of the synthetic prostaglandin F2αanalogue latanoprost have been described.1 We would like to report a case of choroidal detachment following extracapsular cataract extraction in a patient treated with topical latanoprost.
A 78 year old man initially presented with primary open angle glaucoma in 1981. This was well controlled on timoptol and ophthalmic follow up was uneventful except for the development of left age related maculopathy in 1995 reducing the vision to 6/9. In November 1999 the intraocular pressure (IOP) became uncontrolled and a left sided cataract noted. Latanoprost was substituted with subsequent control of the IOP.
He underwent an uneventful left extracapsular cataract extraction by a traditional, non-phacoemulsification technique at another facility in January 2000 (the operating surgeon did not perform phacoemulsification on any cataract patient). Postoperative drops were betamethasone, chloramphenicol, and latanoprost. Immediately postoperatively he experienced nocturnal eye pain and subsequent photophobia. He also noticed a shadow in his left vision. Two weeks postoperatively he still had persistent eye pain and the IOP was recorded as 25 mm Hg. Acetazolamide (orally) and Timolol LA (MSD) were added to the above medications. Three days later examination revealed a visual acuity of 6/24 and IOP 16 mm Hg. Funduscopy showed the presence of a large temporal choroidal effusion.
An opinion was requested and we first saw the patient 3 days later. Visual acuity was 6/60 at best, and examination revealed corneal folds, a marked anterior uveitis with 3+ cells, and a 360 degree choroidal detachment most marked temporally. The IOP measured 10 mm Hg. The latanoprost, chloramphenicol, and acetazolamide were stopped, the Timolol LA continued and dexamethasone 0.1% 2 hourly and cyclopentolate 1% twice daily commenced. Three days later the choroidal detachment had absorbed completely and there were no signs of uveitis. The IOP was 22 mm Hg and the visual acuity had improved to 6/12 at best.
The development of choroidal detachment in a patient with primary open angle glaucoma following cataract extraction has been described.2 However, this patient had previously had a trabeculectomy, undergone phacoemulsification, and had severe hypotony postoperatively. In another report choroidal effusion and hypotony were noted in a patient who 8 months before commencing latanoprost had undergone a combined cataract extraction and trabeculectomy.1 It is likely that, in our case, the choroidal detachment was present from a short time following surgery in view of the subjective shadow in the patient's vision. It would appear that the detachment developed and persisted in the presence of an elevated IOP. Withdrawal of the latanoprost led to complete resolution of the choroidal detachment but the IOP remained elevated. Uveal effusion has been noted following phacoemulsification without concurrent use of latanoprost. However, in this study all effusions were small and correlated with the presence of hypotony following surgery.3
Latanoprost would appear to lower IOP by increasing uveoscleral outflow4 and it has been suggested that the increased outflow facility while on latanoprost may contribute to hypotony and the development of choroidal effusions.1 2 Although our patient may have had an episode of hypotony immediately following his surgery, IOP measurements did not suggest this. The possibility of latanoprost initiating or potentiating choroidal detachment in the absence of hypotony following cataract extraction should therefore be considered. This hypothesis is supported by the presence of significant uveitis in this case some time following the surgery.
To our knowledge there have been no studies examining the incidence and severity of uveitis following cataract surgery where latanoprost has been continued. This case emphasises the possibility that idiosyncratic reactions can occur in patients undergoing surgery while continuing to use antiglaucoma medications which may potentiate the inflammatory response. Such patients may require more frequent review and should be warned to attend urgently if unexpected symptoms occur in the early postoperative period. Surgeons who perform cataract surgery on eyes in which the breakdown of the blood-aqueous barrier is expected to be greater than that produced by routine phacoemulsification surgery should consider substituting another IOP lowering agent for latanoprost in the immediate preoperative and postoperative period.
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